a 69 yr old male with pedal edema

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Chief complaints:-

Pedal edema(pitting type) since 20 days

Decreased urine out put since 2-3 days

Shortness of breath since morning

Cough with sputum since morning 

History of presenting illness:-

Apparently patient was asymptomatic 20 days ago,developed pedal edema, gradually progressed to the knee(pitting type).Went to local hospital for used some tablets after which he developed anuria but pedal edema did not subside.

Daily routine:-

He usually gets up early in the morning and and eats break fast at 6-7am and goes to field for farming.He comes back at 6pm and and has dinner by 8pm and sleeps.

But 3 years ago he had leg trauma in which his both the hip joints got fractured.Hence rods were inserted.Since then he is not able to stand and walk and is bed ridden.So he stopped working and stays home.

History of past illness:-

Known case of  

Diabetis mellitus type 2 since 15-20 years

Leg trauma causing hip joint fracture 3 yrs       ago.Due to this he is bed ridden.

Shortness of breath since many years               which is associated with cough and   wheezing.

Surgical history:-

He got inserted with two rods in hip joint due to fracture caused by leg trauma.

Drug history:-

For diabetes-

 Tab.Metformin 500mg

For pain in the hip-

 Tab.Aceclofenac and paracetamol-100/325mg

Personal history:-

Diet-mixed

Built-low 

Appetite-decreased

Sleep-decreased 

Bowel movement-normal

Bladder movement-decreased 

Allergies- absent

Addiction-alcohol occasionally

 Bidi-1 pack for 2 days

Family history:- not significant 

General examination:-

Pallor,pedal oedema present

Ictreus,cyanosis,clubbing,lymphadenopathy absent

Vitals-

Temperature-98.9F

Pulse rate-96/min

Resperatory rate-28/min

Bp-140/90

Spo2-50%o2

Grbs-60%mg

Systemic examination:-

CVS

Cardiac sounds S1 and S2 present.

No thrills or murmurs.

Apex beat heard in 6th intercostal space lateral to mid clavicular line

Respiratory system

Chest is symmetrical, barrel shaped on inspection.

No visible deviation of the trachea, supraclavicular hollowing or unilateral sternocleidomastoid prominence.

No drooping of either shoulder.

There appears to be a retraction near the 7th intercoastal space on both sides.

On palpation, inspectory findings were confirmed. Trachea in midline, no intercoastal crowding, no rosary beads appearance at costochondral junctions. Pain is present at the site of retraction in the 7th intercoastal space. No dilated veins. Chest movements were normal, symmetrical. Tactile fremitus was more apparent on the right side.

On percussion, no dullness or abnormality was noted.

On auscultation, Bilateral crepts were present and wheezing was noted.

CNS

The patient is conscious, drowsy.

Speech is normal.

No neck stiffness. Kernig's sign is absent.

Abdomen

Normal shape. No tenderness.

No palpable mass. Liver and spleen not palpable.