Case presentation -2

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 A 60 yr old male presented to opd with chief complaint of shortness of breath and bilateral pedal edema.

History of present illness :patient has a history of coronary artery disease in January and was diagnosed to be having myocardial infraction.

History of past illness:patient was diagnosed with diabetes 2yrs ago and has a history of loss of consciousness while going to washroom.he was on irregular medication and stoped as sugar levels were normal . again he started regular medication since 5 yrs .patient is also a known case of hypertension and chronic renal failure.

Personal history:he is married . patients follows a mixed diet with normal apatite.he is suffering from constipation and micturition is normal.patient has adequate sleep.he has no allergy to known drugs . He consumes alcohol occasionally (90-180ml) from age of 20 yrs and stopped it 8months back.

Family history:patient father was a known case of kidney failure.

General examination:patient is conscious, coherent and cooperative.moderately built and nourished.bilateral pedal edema and pallor are seen .no cyanosis .no lymphadenopathy.no clubbing.no icterus.

Vitals:.    PR:92beats/min

                 RR:24cycles/min

                 BP:130/80mm of hg

                 Spo2:94%

                 Temp:98.7F

                 GRBS:175mg/dl

Systemic examination:

CVS:chest wall is bilaterally symmetric,no precordial bulge,no thrills,no cardiac murmurs.

JVP- normal,,S1 and S2 are heard

Respiratory system: dyspnoea-yes;wheeze-no

Position of trachea-central,breath sounds-vesicular, adventitious sound- rales

Abdomen:shape of abdomen-obese,no bruits,no tenderness,no palpable mass,no free fluid,bowel sounds- yes,hernial orifices- normal

CNS:speech -normal,patient is conscious,no signs of meningeal infection, reflexes are normal.

Investigations

Provisional diagnosis:chronic renal failure and coronary artery disease-1yr back

Treatment :    inj:lasix. 40mg IV stat

                         Tab:ecospirin.  75mg.  OD

                          Tab:amlong.   50mg.   OD

                          Tab:vidagliptin.  50 mg.   OD

                          Tab:pan      40 mg.    BBF

                          Syp:lactulose.  10ml.  TID