70 year old female patient

 70 year old F    C/o Generalized body swelling since 1 month.

Distension of abdomen since 1 month 

SOB on exertion since 1 month




HOPI

Patient was apparently asymptomatic 6 years back, then one day after having her food while walking to wash her hands she suddenly felt giddiness and fell down following which she was taken to near by RMP and referred to higher centre there, she was diagnosed to have  right femur fracture and Denovo HTN . Then she was taken to near by quack and pop cast was applied for right leg following which she had recovery. 

She used  anti hypertensives for 1 month then stopped, now since 1 month she developed generalized body swelling which is pitting type associated with distension of abdomen and SOB on exertion and loss of appetite.

No h/o chest pain, giddiness, palpitations


PAST HISTORY:

 Not known case of DM,CKD,CVA,CAD

TREATMENT HISTORY:

 Hypertensive(not on medication)


PERSONAL HISTORY: 

Appetite -  Lost 

Diet - Non vegetarian

Bladder and bowel movements - Regular

Sleep - No

No known allergies 

No  addictions.

FAMILY HISTORY 

No DM,HTN, Heart disease, Cancer, TB, Asthama 

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative. Well oriented to time, place and person.

Mild pallor. No icterus, cyanosis, clubbing, lymphadenopathy.

Pedal edema - B/L pitting type.

Vitals

 Temp: afebrile 

PR- 88/Min    

RR- 20/Min

BP- 110/70 mmHg

Spo2 -96%at RA


SYSTEMIC EXAMINATION

CVS- No thrills, S1 S2 heard, no murmurs


RS- NVBS,  Crepitus present Bilaterally.


P/A - Distended, non tender, palpable mass Liver, free fluid present- Dull note on percussion, Shifting fluid present


CNS- NFND

Tone, power and reflexes are normal.




                           



INVESTIGATIONS: 

CBP- 

Hb- 12.     TLC- 9300.    Plt - 2.97

RFT-

U-31.   Cr.1.2.    Na+ 136.   K+ 4.0.   Cl- 100

CUE- 

pus cells-2-3 cells.   RBC- nil, sugar-nil, ALB- nil.

LFT:

TB-1.10.   DB- 0.42.     AST- 37.      ALT-21.    ALP- 180.     TP- 5.8.    Alb- 3.12













Provisional diagnosis  dilated cardiomiopathy with heart                                        

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