A 70 year old man with SOB and pedal edema

 This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs.


Our patient is a 70 year old farmer living in a rural setup. 

Chief complaints : 

Patient was admitted in the ICU on 9/9/22 in the afternoon with complaints of SOB on doing activities ( walking), easy fatiguability? and pedal edema. 

History of presenting illness:

The patient had already consulted a local  hospital for his pedal edema for which he was  given IV? And the pedal edema subsided after passing urine. 

History of past illness

He also tells  that he has recurrent episodes of fever and associated SOB since past 3 years. He used to take tablets and the fever would subside.

N/k/c/o Diabetes, Hypertension, TB or asthma. 

Addictions: Alcohol consumption - 3 times a week( since past 40 years). Beedi smoker .he stopped after the onset of signs of pedal edema. 

Family history : His wife is a known diabetic and has asthma. 

Surgical history? 

Drug history : none. He has a history of blood transfusions.( how many and when?) 


Personal history :

Patient has a mixed diet. Diet???? 

Difficulty in falling asleep? Sleep pattern? 

History of weight loss since 1 year.He was 58 kgs 1 year ago later it was 41 kgs. At present he is 55 kgs. 

Decrease in appetite. 

Normal bowel movements and normal micturition( times?)( decreased urine output?) 

General examination

Pallor +

Icterus -

Cyanosis + 



Lymphadenopathy -

Pedal edema + pitting type

Vitals? 
Per abdomen? 


Systemic examination

CNS : Patient is consious and coherent. Oriented to time place and  person. 

CVS

Inspection:

Raised JVP. 

Shape of chest : bilaterally unequal with pectus excavatum. 


Visible apex beat in the 5th IC space. 

https://youtube.com/shorts/N7GT6bl4-6o?feature=share

No distended veins, scars, deformities seen. 

No abnormal pulsations seen. 

Palpation

Trachea  central

Apical impulse: diffuse and  hyperdynamic. 

Parasternal heave : grade 1 (visible but not palpable). 

Cardiac murmurs present. 

Percussion

Right and left heart borders identified( dull note elicited) 

Auscultation??? 

RS??? 

 Investigations:






Treatment. 

Inj Optineuron

100ml NS/IV

T ecosprin

Nebulisation with budecort 12 th hourly. 

T. Carvedilol. 3.125mg PO/BD.

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