GM e-log
K Aravind,roll no 55,9th sem.
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A 67 year old Male R/O Devarakonda , came to the casualty 5days back with complaints of Shortness of breath since 10 days and pedal & facial edema since 8 days.
History of presenting illness;
Patient was apparently asymptomatic 10 days back , then he developed Shortness of breath which is insidious in onset, gradually progressive in nature, aggravating on exertion and relieved on taking rest, progressed from grade II to grade III- IV (Modified MRC) Orthopnea, Paroxysmal nocturnal dyspnea present.
He also came with complaints of Bilateral pedal edema below knees , facial puffiness and periorbital edema since 8 days , insidious onset, gradually progressive in nature , no diurnal variation, pitting type I. C/o decreased urine output and decreased appetite since 5days.
No C/o chest pain, palpitations, profuse sweating, No c/o fever, cold,nausea,vomiting.
Daily routine:
Waking up at 6: 00 am, breakfast as idli/upma at 8:00 am . He used to have his lunch as rice and curry , sambhar/rasam at 1: 00 pm .He usually haves his dinner as chapati/upma/rice and curry at 8:00pm and goes to bed by 9:00 pm. The patient used to lead a normal life before this 15days
Past history;
: K/c/o asthma since 10yrs -on medication.
K/C/O HTN 6 yrs ago and used medication for 3 yrs and stopped as BP was under control H/O TB 30 yrs ago.
N/K/C/O DM, CAD, CVD, Thyroid, epilepsy .
Family history; N/K/C/O DM, HTN, Asthma, Epilepsy, CAD, CVD, TB, Thyroid.
Personal history;
Mixed diet
decreased appetite.
Sleep adequate
Urinene output decreased .
Bowel movements: Regular.
Addictions: Alcohol occasionally.
Allergies: no known.
General examination;
Patient is drowsy due to sedation, coherent to time , place, person.
Ht: 155cm
Wt: 58 kg
Pallor: present.
Icterus: absent .
Clubbing: absent .
Cyanosis: absent .
Koilonychia: absent .
Lymphadenopathy.absent .
Vitals:
Temp: 98 F
BP: 90/60 mmHg
PR: 102 bpm
RR: 15 cpm
SpO2: 100% at 5 litre O2
GRBS: 126 mg% .
Systemic examination;
RS:
Orthopnea + Paroxysmal nocturnal dyspnoea + wheeze + Central position of trachea NVBS + .
CVS:
S1 S2 heard No murmurs No thrills .
ABDOMEN:
Shape of abdomen: mildly distended No tenderness No palpable mass No bruits Liver and spleen- not palpable Bowel sounds heard .
CNS:
drowsy but arousable no neck stiffness kernig's sign negative cranial nerves: normal motor - intact ,sensory - intact.
Glasgow scale E2V2M2 = 6/15 .
MUSCULOSKELETAL SYSTEM:
normal SKIN: normal ENT: normal TOOTH & ORAL CAVITY: normal .
Physical examination;
Provional diagnosis;
Altered sensorium ? AKI ??
HEART FAILURE(ET 51%)
ANAEMIA.
Investigations;
2/12/2023:
. 
6/12/2023
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