50 Female with SOB , PEDAL EDEMA

 A 50 year old female from nalgonda ,farmer by occupation has come with chief complaints of

• SOB since 15 days

• Pedal edema  since 15 days


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 3 years back when she developed SOB grade 2 and pedal edema which then extended to face and body causing generalised edema .

She then went to nalgonda hospital and used medications prescribed and the symptoms subsided.

6 months back in jan 2022 she developed the same symptoms and again went to nalgonda hospital and took medications and symptoms subsided.

She was also diagnosed with hypertension and is not on treatment.

Now 15 days back she had developed the same symptoms SOB grade 3 and pedal edema ,generalised edema and went to nalgonda hospital and since the symptoms were not subsiding they came to Kims.

(First she developed pedal edema which extended and caused generalised edema

7 days after this she developed SOB grade 3).

She also complains of fever for 3 days and cough after treatment started here.



PAST HISTORY

Hypertensive since 6 months and is not on medication

Not a k/c/o Diabetes, Epilepsy,  Tuberculosis.


TREATMENT HISTORY

Not significant


PERSONAL HISTORY

Daily routine :

Wakes up at 6AM

Does household work

Breakfast

Goes to work at 9AM

Lunch at 1 PM

Returns at 5 PM

Does household work

Eats at 8PM

Sleeps at 9 or 10 PM



Diet: mixed

Appetite: decreased

Bowel and bladder movements :regular

Sleep -decreased/ disturbed

Addictions :none


GENERAL EXAMINATION

Patient is conscious, coherent and cooperative

Well oriented to time place person

Moderately built and nourished


No Pallor

No Icterus

No Cyanosis

No Clubbing

No Lymphadenopathy

Edema : bilateral pedal edema







VITALS

BP 140/80 mm/hg

PR 92bpm

RR 18cpm

TEMP febrile

SP02 97%

GRBS 99mg%


SYSTEMIC EXAMINATION

RS : NVBS ,BAE+, crepts

CVS: S1 S2 +

CNS: NFD

PA: soft, non tender, hepatomegaly


INVESTIGATIONS

Random blood sugar-91mg/dl (16/7/22)

anti HCV antibodies rapid-non reactive











PROVISIONAL DIAGNOSIS

Cardiorenal syndrome (type II)


TREATMENT

1. Fluid restriction 1.5l/day

2. Salt restrictions <2g/day

3. Inj lasix 40mg TID

4. Tab Dolo 650mg TID

5. Inj Neomol 100ml IV SOS

6. Syrup Ascoryl 10ml TID

7. Inj Monocef IV BD

8. Vital monitoring 8th hourly 

 


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