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Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
CHIEF COMPLAINT:
A 70 year old male patient resident of annaram ,who is farmer by occupation presented to the opd with chief complaints of pedal edema ,sob , and generalized weakness since 20 days.
HISTORY OF PRESENT ILLNESS
Patient is apparently asymptomatic 3 months back then he developed sob which gradually progressed from grade II to grade III . This was associated with pedal edema which is pitting type up to the knee and not associated with chest pain and palpitations.
Patient has history of fever and chills (on and off) since 2 months.
Patient has no facial puffiness and no decrease in urine output.
Patient has orthopnea and paroxysmal nocturnal dyspnea .
PAST HISTORY
Patient is diagnosed with dengue 1 month back.
Patient is k/c/o diabetic since 10 years .
Patient is k/c/o of seizure disorder since 5 year and he is on medication .
Patient has no history of hypertension, asthma,tuberculosis,CAD,CVD.
Patients undergone 2 times blood transfusion.
No history of blood loss, hemorrhoids, hematuria.
PERSONAL HISTORY
Diet is mixed
Sleep is adequate
Bowel movements are irregular
Micturition - normal
Appetite - normal
Addictions - occasional alcoholic
FAMILY HISTORY
No similar complaints in the family .
GENERAL EXAMINATION
Patient is conscious,coherent and co-operative.
Patient is moderately built, nourished .
Edema is present which is of pitting type.
pallor - present
No cyanosis ,icterus and clubbing.
No generalized lymphadenopathy
Vitals:
Pulse : 82bpm
Temperature: afebrile
Respiratory rate : 24cpm
B.p : 150/80
Spo2 : 99%
SYSTEMIC EXAMINATION
CVS
S1 and S2 are heard
No cardiac murmers
No thrills are present
Apex beat is present in the 6 th intercoastal space .
RESPIRATORY SYSTEM
Dyspnea is present
No wheezing
Bilateral air entry - positive
Position of the trachea - central
No adventitious sounds
ABDOMEN
No tenderness
No palpable mass
Abdomen soft and non - tender .
Bruits are not present
Liver and spleen are not palpable
CENTRAL NERVOUS SYSTEM
Patient is conscious
Speech - normal
Meningitis- absent
Clinical images
PROVISIONAL DIAGNOSIS
Severe anemia - iron deficiency
Coronary artery disease
Chronic kidney disease ? Acute coronary syndrome ?
Treatment
Fluid restriction <1.5 l/day
Salt restriction <2.4g/day
Tab Lasix 20mg pO/bd
Tab ecosprin 75mg po/od
Tab carbamazepine -200mg
Tab zoryl M2 PO/BD
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