60F with SOB, pedal edema and old pulmonary kochs.

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60year old female came with c/o SOB since 4days and

Pedal edema since 10days productive cough since 4days

Decreased urine output since 1week

Fever since 4 days.

Pt was apparently alright 20years back,after which she developed low grade fever on and off associated with productive cough,generalised weakness and then was diagnosed with pulmonary kochs and used ATT for 6months

10days back pt developed B/L pedal edema pitting type which has gradually progressed associated with facial puffiness

H/o decreased urine output,no abdominal distension

Her SOB intially grade 2 gradually progressed to grade 4

Associated with PND,no chest pain , occasional palpitations,no burning micturation,on and off cough with scanty whitish sputum

No h/o wt loss

Not a known Diabetic and hypertensive

O/E 

Pt c/c/c

No pallor

No cyanosis 

 clubbing ++

 Pedal edema - B/L pitting type

No lymphnodes

Bp 130/70mmhg

PR 102bpm

Spo2 @ RA 70% with 4 lts Oxygen 98%

Afebrile to touch

CVS: no visible pulsations

JVP raised

RV apex

Palpable p2

Parasternal heave +

Pansystolic murmur+

RS

Inspection:

Shape of chest barrel AP 22, TV: 21 

AP:TV = 1:1

Supra and infra clavicular hollowing+

Reduced chest expansion

Intercostal retractions+

Palpation:

All inspectory findings are confirmed

Reduced chest expansion 0.5cms.

Both sides Supra , infra clavicular area,both supra scapular areas.

Increased tactile and vocal fremitus.

Percussion: 

Dull note over B/L SSA,ICA.IMA

Auscultation: 

Decreased air entry on both sides

B/L crepts in IAA,IMA,ICA, SSA

B/L expiratory wheeze in IAA,IMA.

P/A: 

Soft and Non tender, 

No organomegaly

bowel sounds present.

CNS:

HMF Intact

Cranial nerve examination normal

Motor and sensory examination normal

No signs of cerebellar dysfunction.

Investigations:

Pulmonology referal taken

Treatment:

Inj. Lasix 40mg iv bd

Neb duolin 6th hourly

         Budecort 8th hourly

Vitals monitoring.