A 80year old female with SOB since 3days Pedal edema since 1month





patient was apparently alright 3days back then she had shortness of breath which is grade 2 insidious in onset gradually progressive to 
grade 4 

Orthopnea is present 

No H/o PND 

Pedal edema present since 1month which was pitting type no 

Fever since 3days ago low grade type which relived on medication 


Past history 

K/c/o CKD , HTN,DM-2 since 15years 

K/c/o CAD 1month back advised for DTCA but not done 

For diabetes she is using linagliptin 5mg OD

HTN on amlodipine 5mg OD 


Personal history 

Appetite normal 

Bowel  movements regular ,

Urine output decreased 

No Addictions 

On examination 


  GENERAL EXAMINATION:

Patient is conscious,coherent and cooperative, moderately built and malnourished

Pallor: mild pallor present 

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: present


VITALS:

Temperature: 98 .2F

Pulse: 116beats/minute

Blood pressure:130/70mm Hg

Respiratory rate:20cpm

SPO2 -83%at room air ,93%on 10L O2

GRBS 144mg/dl 



Systemic examination 


CVS - S1 S2 heard

R/S - 

No wheeze 

Diffuse crepts present

no palpable mass,

Trachea- central

Vesicular breath sounds heard


P/A - 

Scaphoid,Umbilicus inverted , No abdominal distention,no  visible pulsations,scars and swelling

Soft, non tender, no organo megaly

BOWEL SOUNDS HEARD

CNS - NO focal deficit found.


PROVISIONAL DIAGNOSIS 

acute pulmonary edema secondary to heart failure 


Investigation 

CUE 


HEMOGRAM


LFT


RFT


ECG 13/12/23




ECG (12/12/23 11:30pm)



ECG ON 14/12/23 









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