General medicine case -5

 This is an online elog book to discuss our patient de-identified health data shared after taking his/her /guardians signed informed consent.Here we discuss our individual patients 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 evident based input.

A 55 year old male pt, labour by occupation,    came to the casualty with clo SOB , generalized body swelling, and decreased urine output.

History of present illness: patient was apparently asymptomatic since last 5 days. He the developed SOB, swelling , body pains, decreased urine output 

Past history:  patient is diabetic since 10yrs and uses glimiperide 2mg and he has hypertension since 2yrs and uses telmisartan 40mg

Patient has a surgical history of left leg amputation and was treated by below knee prosthesis .

Family history : patients father was diabetic .

Personal history: 

Diet: mixed 

Appetite : decreased

Sleep : adequate

Bowel bladder movement: decreased micturation

Habits: patient is alcoholic since 30 yrs 

And smoker since 10 yrs ( 1 pack of both bidi and cigarette per day)

General examination:

pt is conscious, coherent, cooperative

Temp: afebrile

Bp: 130/80 mmhg

 SPO2 -99%,

GRBS 78 Mg/dl, 

RR-20 cpm

P/A: soft , non tender, no bowel sounds present

Systemic examination:

CVS- S1, S2 heard, no murmurs, no added sounds.

, trachea central in position.

P/A- soft, non-tender, no palpable mass or swelling.

CNS- NAD.

Investigations:

Provisional diagnosis:

Acute kidney injury

Right heart failure.