70 year male with Shortness of breath and pedal edema

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 70 yr old male who is a resident of  nalgonda, came to OPD with chief complaints of Shortness of breath since 1 month and pedal edema since 20 days.

HOPI:

Patient was apparently asymptomatic 1 month back then he developed Shortness of breath which is of grade 3,SOB even present while he was talking and  after 10 days he developed pedal edema  which extended upto waist so he was taken to a nearby private hospital and over there he was investigated and his hemoglobin was found to be 3.9gm% so in that hospital Blood transfusion done and was discharged.

After discharge,pedal edema present upto knee and SOB decreased while talking.

  He didn't feel better after dicharge  so came to our hospital for treatment.

He has a history of shortness of breath when he suffered from any kind of fever in his past, but that used to decrease the moment when the fever got subcided.

PAST HISTORY -

Pt is not a known case of HTN, TB, DM and CAD, asthma, epilepsy

PERSONAL HISTORY -

Appetite:normal

Diet:mixed

Bowel and bladder:regular

Sleep: adequate 

Addictions - He's a chronic alcoholic and daily drinks 90ml since the past 40yrs

He's also a chronic smoker and smokes one pack of beedi cigarettes since the past 40 years.

FAMILY HISTORY - 

not significant 

GENERAL EXAMINATION -

Patient is conscious coherent cooperative and well oreinted to time and space.

Pallor present and pedal edema present

No icterus, cyanosis, clubbing, and lymphadenopathy.

Vitals:

BP: 100/70mmhg

PR:80

RR: 20 cpm

Temp: afebrile .

SYSTEMIC EXAMINATION - 

CVS:S1 S2+, pansystolic murmur heard

RS: BAE+, right infrascapular crepts and rt. Infrascapular wheeze heard. 

CNS: no focal neurological deficits.

P/A:soft,non tender

Clinical Images:

Investigations:

TREATMENT -

-Inj Lasix 20mg IV BD

-Inj Optineurin IN 100ml NS IV

-T. Ecosprin AV Po OD 

-Nebulization with Budecort