52 year old male patient with SOB

 A 52 year old male patient,a vegetable vendor by occupation and resident of miryalguda came to the casualty with 

chief complaints of shortness of breath since 25 days


HISTORY OF PRESENTING ILLNESS:

Patient is apparently asymptomatic 6 months ago then he developed shortness of breath which is insidious in onset, intially it was for heavy work (class 1) progressed to producing symptoms even on rest (class 4) for which he went to local hospital 1 month back,where he is diagnosed with Acute kidney injury 

no aggrevating and relieving factors 

 orthopnea present, Trepopnea present, PND since 1month

Patient has bilateral pedal edema extending upto the knee (pitting type) since 1 month which was insidious in onset and gradually progressed with no aggrevating and relieving factors 

No history of fever

No history of chest pain

No history of syncopal attacks


DAILY ROUTINE:

Patient wakes up at 6 am and have a cup of tea and eats breakfast at 8am and goes to work evening he'll have cup tea and at 8pm he returns back to home and will have his dinner and goes to bed at 10pm

Since 25 days he is not able to do his regular physical activity. He couldn't lift heavy weight and having Dyspnea with regular physical activity


PAST HISTORY:

No history of similar complaints in the past.

He is not a known case of Hypertension, diabetes mellitus, asthma, epilepsy, TB, Thyroid abnormalities 

Patient underwent hernia surgery on both the sides 6 years back on right side and 4 years back on the left side


PERSONAL HISTORY:

Diet: Mixed

Appetite:Normal 

Sleep: adequate 

Bowel and bladder movements: regular 

Addictions: alcoholic (drinks daily 90ml)  from the past 4 years and gutka since 20 years 


FAMILY HISTORY:

not significant


GENERAL EXAMINATION:

Patient is conscious coherent cooperative, Moderately built and moderately nourished well oriented to time place and person

 Pallor-present



Icterus-absent 

Cyanosis-absent 

Clubbing-absent 

Generalised lymphadenopathy-absent

B/L Pedal edema-present


Vitals:

Temperature- 98F

Pulse rate- 66 bpm,regular 

Respiratory rate-16 cpm

Blood pressure -130/70 mm of hg 


 SYSTEMIC EXAMINATION:

CVS:

S1 S2 heard

Chest wall- symmetrical

No scar, No sinuses

Apex beat felt at 6th ICS shifted laterally to left

Jvp:Elevated (visible pulsations can be seen)



RS:

BAE-present,Normal (mild diminished bilateral) vesicular breath sounds heard 

percussion: shifting dullness present bilaterally

CNS:

No focal neurological defects

ABDOMEN:

Soft and Nontender

No Hepatomegaly

Spleen is not palpable 



Provisional Diagnosis:
Heart Failure with bilateral Pleural effusion 
with Acute kidney injury 

Investigations:

ECG:

Rhythm: regular 


USG:

2D ECHO:








Chest Xray:


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