74yrs old male patient came to casualty with C/O SOB since 7days, C/O giddiness since 7days C/O pedal Edema since 6days

74yrs old male patient came to casualty with 

C/O SOB since 7days,

C/O giddiness since 7days

C/O pedal Edema since 6days

HOPI 

Patient was apparently asymptomatic 7days back ,then he developed SOB on exertion,progressed from grade 2 to grade 3 ,he was not able to walk till washroom associated with on and off giddiness,B/L pedal Edema

No h/o fever,cold,burning micturition,vomiting,loose stools

No h/o decreased urine output 

No h/o hematuria,hematemesis,Malena 

Past history 

N/k/c/o Dm,HTN,epilepsy 

Personal history 

Diet -mixed

Appetite-normal 

Bowel and bladder -regular

He is an alcoholic-weekly thrice 90-180ml

He smokes 10-15beedis /day since 50yrs

General examination 

Pt is C/C/C

No pallor/icterus/cyanosis/clubbing/lymphadenopathy 

Vitals-

Temp-98F

Pr-80bpm

Rr-17cpm

Bp-130/80mmhg 

Spo2-98% at RA

Systemic examination 

Cvs-S1,S2+,no murmurs

Rs-BAE+,B/l crests present in IAA,IMA.Wheeze present in B/L IMA,ISA

P/A-soft,non tender

Cns-NAD

Provisional diagnosis-

Anaemia 2° to IRON DEFICIENCY/

HFPEF (EF: 55%)

B/L PLEURAL EFFUSION 2° to HEART FAILURE (R>L)

With ?COPD 

With Alcohol and Tobacco Dependence Syndrome

With H/O - Haemorrhoids

Investigations 

Hemogram 

Hb-4.1gm/dl 

TLC-9400cell/cumm 

Plt-4.15L/cumm 

Lft

Total bilirubin-1.50mg/dl 

Direct bilirubin-0.93mg/dl 

ALP-248IU/L

Bgt-B+

RBS-99mg/dl 

Reticulocyte count-1.2%

Rft-

Urea-25mg/dl

Creatinine-0.7mg/dl 

UA-5.3mg/dl

Calcium-10mg/dl

Phosphorus-4.7mg/dl 

Sodium-142mEq/l

Potassium-3.3mEq/l

Chloride-98mEq/l

Usg chest-b/l pleural effusion (rt-mild,lt-moderate)

Treatment 

1. Inj.lasix 40mg IV TID 

2. Neb.Duolin 1resp and budecort 1 resp TID 

3. Tab.pan40mg po/OD 

4. Syp.grillintus 10ml po/bd

5. O2 inhalation sos(if spo2<92%)

1unit PRBC transfused on 25/1/22

On 27/12/22