53M WITH SOB AND PEDAL EDEMA
Case History and Clinical Findings C/O PEDAL EDEMA SINCE 2 MONTHS C/O SOB SINCE 3 DAYS C/O DECREASED URINE OPUTPUT SINCE 1 WEEK HISTORY OF PRESENTING ILLNESS: PT WAS APPARENTLY ALRIGHT 1 YEAR BACK THEN HE WAS DIAGNOSED WITH CKD AND WAS ON CONSERVATIVE MANAGMENT . PATIENT HAD DECREASED URINARY OUTPU SINCE 1 WEEK NO HESITANCY, DRIBBLING OF URINE PEDAL EDEMA SINCE 2 MONTHS, PITING TYPE UPTO KNEE SOB SINCE 3 DAYS GRADE IV, ORTHOPNEA+ NO PND , NO CHEST PAIN, PALPITATIONS PAST HISTORY: K/C/O DM II SINCE 7 YRS ON INSULIN K/CO HTN 1 YEAR ON CLINIDIPINE 10MG PERSONAL HISTORY : DIET MIXED APPETITE DECREASED SLEEP ADEQUATE BOWEL REGULAR ADDICTIONS NONE GENERAL PHYSICAL EXAMINATION PATIENT IS CONCIOUS COHARENAT COOPERATIVE VITALS PR 90 BPM BP 130/80 MM HG RR 17 CPM TEMP 98.7 F GRBS : 102 MG/DL SPO2 99 @ RA CVS : S1 S2 + RS : BAE +, TRACHEA CENTRAL , NVBS HEARD, B/L BASAL CREPTS PRESENT CNS : HMF INTACT , NO NEUROLOGICAL DEFICITS P/A : SOFT , NT. COURSE IN THE HOSPITAL 53 YEAR