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49 year old male, house contractor by occupation,  came to Medicine OPD with complaints of : 

Chief complaints

Right lower limb swelling since 10 days, fever since 5 days

History of presenting illness

Patient was apparently asymptomatic 10 years back then he developed progressive swelling of right lower limb and diagnosed with filariasis for which he was prescribed medicines by a local doctor

10 year back he was diagnosed with diabetes mellitus and hypertension and since then using antihypertensives( nifedipine) and anti diabetics( glizide)

- 3 years back he developed pedal oedema and went for further evaluation and diagnosed to have chronic renal failure ?

- 2 years back he suffered from COVID-19 following which he had shortness of breath at rest (grade 4) and chest pain for which he went to co-operate hospital in Hyderabad and diagnosed to have inferior wall myocardial infarction, So he was treated with streptokinase. At that time coronary angiogram was not done in the view of high serum creatinine levels

- After 1 month cononory angiogram was done to recanalized the right coronary artery, later he had many episodes of SOB(grade 4) and diagnosed with severe heart failure and hydralazine four times a day

- since 10 days they is swelling of Right lower limb with no local rise of temperature and fever since 5 days

Daily routine

Wakes up at 5am 

walking for 1hour

breakfast - 7.30

Goes to work- 8am

1pm - lunch

4.30pm- tea

6pm - home

8pm - dinner

. - Used to have Alcohol- occasionally but stopped since 4 years 

Past history

Hypertension and diabetes since 10 years and was medications

No history of fever

No history of vomiting 

No history of loose stools

No history of past surgeries

Treatment history

antihypertensives( nifedipine) and anti diabetics( glizide)

-coronary angiogram for re canalisation 

Personal history

Occupation is house contractor

Sleep is adequate

Diet is mixed

bladder is normal

No allergies

Occasionally alcohol consumption 

Family history 

Not significant 

General examination

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished

Icterus - absent

Pedal edema - present 

pallor is present            

 No cyanosis, clubbing , lymphadenopathy .

Vitals :

Temperature- afebrile

Respiratory rate - 20 cpm

Pulse rate - 110 bpm 

BP -  130/80 mm Hg.

Spo2 at room air is 85% on admission 

GRBS - 146 mg%

SYSTEMIC EXAMIN ATION: 

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination: 

INSPECTION : 

      Shape of abdomen- obese

-No tenderness of abdomen 

• Umblicus - normal
• Movements of abdominal wall - moves with respiration 
• Skin is smooth and shiny;
• No scars, sinuses, distended veins, striae

PALPATION : 

No Local rise of temperature

Tenderness absent

Rigidity absent 

hernial orifices normal

Fluid thrill absent

Liver not palpable .

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 

PV examination -normal 

P/R examination -normal 

.

CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++

Gait: normal

Investigations 

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Provisional diagnosis

 

Heart failure with preserved ejection fraction along with chronic renal failure