A 55 year old male with SOB

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A 55 year old male, farmer by occupation and a resident of rajammagudam, came with the chief complaints of 

* Shortness of breath since 1 week

* Pedal edema since 3 days 

* Decreased urine output since 3 days. 



HISTORY OF PRESENTING ILLNESS 


* The patient was apparently assymptomatic 3 years back when he was diagnosed with diabetes when he visited the hospital with complains of fever. He was given tablet pioplus-2(Glimepiride, Metformin and Pioglitazone). He is compliant with his medication. 

  1 year ago patient was having blurring of vision and dizziness for which he went to the doctor and was diagnosed with hypertension and was given amlodipine. He is compliant with the medication. 

The patient complains of shortness of breath since 1 year. It was initially of grade 2(MMRC Classification) that is he has to stop to take breath while walking at his own pace. For this he went to a local doctor and was given a tablet (unknown). 

- The shortness of breath has aggrevated to grade 4 MMRC classification

- The shortness of breath was associated with PND and orthopnea. It was not associated with chest pain or palpitations. 

- The patient also complains of non productive cough since 3 days. 

 The patient has had decreased urine output for the past three days. In the 24hrs before admission he did not have any urine output. 

- He doesn’t have any hesitancy, increased frequency or fullness of bladder. 

Pedal edema since 3 days

He had  first session of dialysis on the day of admission 19/02/22 ( indication was metabolic acidosis ph 7.19)

Other two sessions on 20/02/22 and 21/02/22


PAST HISTORY 

 he was diagnosed with diabetes 3 years ago when he visited the hospital with complains of fever. He was given tablet pioplus-2(Glimepiride, Metformin and Pioglitazone). He is compliant with his medication. 

 diagnosed with hypertension 1 year ago and was given amlodipine. He is compliant with the medication. 

He is not a known case of coronary artery diseases, Asthma, TB, epilepsy. 


PERSONAL HISTORY 

Appetite: decreased 

Diet : mixed

Bowel: normal 

Bladder : decreased urine output 

Sleep: disturbed 

Addictions: nil


GENERAL EXAMINATION :

Patient is conscious,coherent,cooperative coherent, cooperative and well oriented to time and place 

Moderately built and nourished 

Pallor is present 

No signs of Icterus, cyanosis, clubbing, edema, lymphadenopathy 

Vitals : PR - 62bpm

             RR - 20cpm

            BP - 110/80mmHg

           Afebrile

RESPIRATORY SYSTEM :

Inspection :

Chest is bilaterally symmetrical 

Bilateral air entry present ,equal expansion on both sides

Position of trachea is central 

Supraclavicular and infraclavicular hollowness is not seen

Crowding of ribs is not seen

No visible scars, sinuses, pulsations 

Palpation :

Expansion of chest is equal on both sides 

Trachea is central 

Vocal fremitus: resonant note felt

Percussion:

All the lung areas were resonant 

Auscultation :

Normal vesicular breath sounds heard on both sides 

Vocal resonance :resonant in all areas

CARDIOVASCULAR SYSTEM :

JVP:

appears raised




INSPECTION :

shape of the chest is elliptical ,symmetrical 

No precordial bulge, scars, sinuses,dialated veins

No visible pulsations 

PALPATION :

Apex beat felt in 6th intercoastal space

No parasternal heave

AUSCULTATION :

S1, S2 heard, no murmurs 


PER ABDOMEN :

soft, nontender

No helatosplenomegaly 

CNS: imtact











INVESTIGATIONS :19/02/22














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