60 years old male presented with shortness of breath since 15 days on and off

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A 60 yr old male came to the Casuality with the chief complaints of SOB since 15days on and off.

1) History of presenting illness:-

Patient was apparently asymptomatic 15days back then he developed SOB(grade 4) Which was on and off. It is associated with pedal edema which is of pitting type.

- SOB is associated with orthopnoea

- It was not associated with Chest pain, syncopal attacks.

- Patient also presented with an ulcer over left leg due to this reason he went to hospital and is on regular medication, there he was diagnosed with CRF ( chronic renal failure ) and is on regular medication.

- He developed pedal edema 2 months back for which he went to local hospital there he was diagnosed as bilateral CRF and his basline creatinine was 4.5

2) past history :-

- history of seizures in past 

- chronic kidney disease ( CKD )

- COPD

- severe anemia 

3) family history :-

- no significant family history 

4) personal history :- 

- Diet - mixed ( veg and non veg )

- Appetite - reduced

- Sleep - adequate

- Bowel and bladder movements - Regular

- Addictions - alcohol intake since 40yrs (Daily 90 to 180ml)

 -  Smoking 18-20 beedis/Day

Allergies - No known food or drug allergies

GENERAL EXAMINATION :- 

- patient is conscious,cooperative and coherent and well orientes to time, place and person.

- He is moderately built and moderately nourished.

- He was examined after taking consent.

●Pallor - present

●Icterus - absent

●Cyanosis - absent

●Clubbing - absent

● lymphadenopathy - absent

●Edema: bilater pedal edema (pitting type)

Vitals :- 

●Pulse rate - 96bpm

●Bp - 120/80mmhg

●Temperature - afebrile

●Respiratory rate - 26cpm

●SpO2 -  88% at room air and 99% at 6L oxygen. 

SYSTEMIC EXAMINATION .:-

●RESPIRATORY SYSTEM-

- position of trachea -  central

-Auscultation - bilateral Crepts are heard in IAA , ISA.

●CARDIOVASCULAR SYSTEM -

-  S1  S2 heard

- Per abdomen - soft non tender non distended

●CNS- 

-  higher motor functions are intact

INVESTIGATIONS:

● chest x - ray:- 

●Pitting edema:-

●ABG ( arterial blood gases )

●BLOOD UREA :-

●ser

um electrolytes  :-

●serum creatinine:-

● hemogram :- 

●complete urine examination ( CUE) :- 

● liver function test ( LFT ) :-

●Troponin-1 :- 

●HIV 1/2 rapid test :- 

●Hbs-ag :-

● AntiHCV Antibodies :-

●Blood group :-

● blood sugar random :-

●2D ECHO :- 

●ECG :-

●USG abdomen :-

●SARS COV- 2 :-

# Treatment :- 

Tab LASIX 40mg BD

Tab PANTOP 40mg BD

Fluid restriction less than 1.5L/day

Salt restriction less than 2g/day

Tab shelcal OD

Inj erythropoietin 4000 Weekly once

Tab orofer BD

Tab Ecospirin BD

Tab metxl 25mg OD

Tab hydralazine 25mg OD

Neb duolin 4th hourly

        Budecort 6th hourly

# PROVISIONAL DIAGNOSIS :- 

 chronic renal failure with confestive heart failure with reduced ejection fraction with uremic encephalopathy