case of 70yr old male

2d echo This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 70 yr old male, resident of vuttepally, nalgonda, came with chief complaints of 
SOB since 1 month and pedal edema since the past 5 days
HOPI
Patient was apparently asymptomatic 
 5 days ago, then pt. Complained of b/l pedal edema ( pitting type) and SOB. 
No h/o of decreased micrurition
 No h/o of easy fatiguability
No h/o of bleeding per rectum
No h/o of melena
   

Past history

Pt was apparently asymptomatic 1 month back, then he developed SOB grade 4 which was associated with facial puffiness and b/l pedal edema for which he was taken to a private hospital at alalya
He was investigated and his hemoglobin was found to be 3.9gm%. he was given 2  PRBC units and was discharged.

Pt is not a k/c/o of htn tb DM CAD asthma epilepsy.
He's a chronic alcoholic and daily drinks 90mlsince the past 40yrs
He's also a chronic smoker and smokes one pack of beedi cigarettes since the past 40 years.

On admission.
Patient is conscious coherent cooperative 
BP: 100/70mmhg
PR:80
RR: 20 cpm
Temp: afebrile 
CVS:S1 S2+ pansystolic murmur 
RS: BAE+, right infrascapular crepts and rt. Infrascapular wheeze heard. 
CNS: NAD
Speech normal 

REFLEXES-
                        RT.        LFT
BICEPS-.           ++.       ++
TRICEPS-.        ++.        ++
SUPINATOR-    ++         ++
ANKLE. -.         ++.         ++
KNEE-.              ++          ++
P/A:soft,non tender
Pallor seen 

No icterus, cyanosis, clubbing, and lymphadenopathy 

Appetite:normal
Diet:mixed
Bowel and bladder:regular 
Sleep: adequate 
No significant family history

Investigations

usg 
Xray

10/09/22
 Xray 
10/09/22




Xray 11/9/22

Hemogram 11/9/22






Provisional diagnosis: anemia secondary to iron deficiency, DCMP with HF mid ejection fraction (46%)

Treatment.

Inj. Lasix 20mg IV/BD
Tab. Ecosprin PO/OD
Inj. Optineruron in 100ml NS
Nebulization with budecort 12th hourly


Xray 13/9/22


 2d echo Diagnosis: aortic stenosis with calcified aortic valve 
 Discharge summary

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