70F WITH DECREASED URINE OUTPUT AND FEVER

 PT CAME WITH 

C/O FEVER SINCE 4 DAYS 

ASSOCIATED WITH CHILLS AND RIGORS

EVENING RISE OF TEMP PRESENT 

DECREASED URINE OUTPUT SINCE 4 DAYS

C/O ABDOMINAL DISTENSION PRESENT 

SOB SINCE YESTERDAY EVENING 


C/O PEDAL EDEMA AND FACIAL PUFFINESS 


HOPI:


PATIENT WAS APPARANTLY ASSYMPTOMATIC 4 DAYS BACK THEN SHE HAD FEVER FOR 1 DAY WHICH IS HIGH GRADE, SUDDEN ONSET, ASSOCIATED WITH CHILLS AND RIGORS RELIEVED BY TAKING MEDICATION. SOB(GRADE-2) SINCE YESTERDAY WHICH IS GRADUALLY PROGRESSIVE AND PROGRESSED TO GRADE-4 . NO ORTHOPNEA, NO PND


C/O PEDAL EDEMA WHICH IS PITTING TYPE


C/O ITCHY SCALY LESIONS ON DORSUM OF FOOT SINCE 1 YEAR


H/O DECREASED URINE OUTPUT


NO COUGH, COLD,


NO CHEST PAIN, PALPITATIONS, NO ABDOMINAL PAIN, NO NAUSEA, VOMITING, LOOSE STOOLS


PAST HISTORY:


K/C/O HTN SINCE 4 YEARS


NOT A K/C/O DM-II, TB, EPILEPSY, CVA, CAD


PERSONAL HISTORY:

MIXED DIET


SLEEP ADEQUATE


APPETITE NORMAL


BOWEL AND BLADDER MOVEMENTS NORMAL


ADDICTIONS- ALCHOHOL- DRINKS WHISKY 90ML DAILY, STOPPED 10 DAYS BACK


FAMILY HISTORY- NOT SIGNIFICANT


GENERAL EXAMINATION:


PATIENT IS C/C/C


NO SIGNS OF PALLOR, CYANOSIS, CLUBBING, LYMPHADENOPATHY, ICTERUS




EDEMA OF FEET PRESENT


TEMP- 98.8F PR-110BPM RR- 32CPM


BP- 180/100MMHG


SPO2- 92% AT ROOM AIR


GRBS- 111 MG/DL


CVS EXAMINATION: S1S2 HEARD, NO MURMURS


RS EXAMINATION: BAE+, NO ADDED SOUNDS


P/A- SOFT, NON TENDER, BS +


CNS EXAMINATION: NFND

DIAGNOSIS 

HEART FAILURE WITH PRESERVED EJECTION FRACTION (1MONTH) WITH BILATERAL PLEURAL EFFUSION WITH CKD (1MONTH)

HYPERTENSION 4YRS


INVESTIGATIONS

HEMOGRAM 


BLOOD UREA


P.SMEAR


S ELECTROLYTES


CUE 


S CREATINE


CXR 



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