58 year old male with SOB and pedal edema

Kausalya Varma, MBBS 9th semester

Roll no: 59

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.

 I’ve 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 58 YEAR OLD MALE WITH SHORTNESS OF BREATH AND PEDAL EDEMA 

CASE:

A 58 yr old male who is a farmer by occupation came with the chief complaints of bilateral pedal edema and shortness of breath since the past 4 days. He has also had a fever and cough since the past 2 days. 



HISTORY OF PRESENTING ILLNESS:

- Patient was apparently asymptomatic 3 years ago when he noticed poor wound healing for which he consulted a local doctor and was diagnosed with diabetes mellitus and was on oral hypoglycaemic agents since then.
- 6 months ago he complained of giddiness for which he consulted a doctor and was diagnosed with hypertension, for which he was on medication.
- 5 months ago he developed bilateral pitting type of pedal edema which was on and off, aggravated on working, subsided on taking rest. 
- 3 months ago he complained of recurrent generalized body pains which were dragging type,  aggravated on working, and relieved with medications
- One month ago (14/2/2022), he developed SOB grade 4 and orthopnea. 
- History of bilateral pedal edema which is pitting type up to ankles and is associated with periorbital edema. 
- History of decreased urine output.
- History of decreased appetite, vomiting (non bilious, non projectile, food as content) for which he was taken to a hospital in Miryalaguda and was diagnosed as CKD (serum creatinine 9.1 mg/dl)  with anaemia (HB 5.8 , normocytic hypochromic) with pulmonary edema and uremic gastritis, 
and was referred to KIMS, Narketpally. 
- Patient got admitted in our hospital on 19/2/2022. He was managed symptomatically and five sessions of dialysis were done with 2 units of PRBC  transfusion and got discharged on 24/2/2022
- On 8/3/2022 he came with the complaints of bilateral pedal edema, SOB, decreased urine output and facial puffiness for the past 4 days.
- Fever and cough since the last 2 days
 - History of BILATERAL PEDAL EDEMA  which is pitting type, up to the knees. 
- History of SOB, which was aggravated on working and relieved with rest. 
- No history of chest pain, palpitations, paroxysmal nocturnal dyspnea. 
- History of DECREASED URINE OUTPUT and facial puffiness. 
- No history of hematuria, Loin pain, thin stream of urine. 
- History of FEVER which is low grade, not associated with chills and rigors. 
- No history of headache, blurring of vision, vomiting, Diarrhoea, Nasal discharge, burning micturition. 
- History of DRY COUGH which is insidious in onset,  Gradually progressive, No positional and diurnal variation.




PAST HISTORY:

Medical history-
He’s a known case of Diabetes mellitus type 2 since 3 years and medication. 
He’s a known case of Hypertension since the last 6 months and is on regular medication.  
No history of Bronchial asthma, TB, Thyroid disorders, CVA, or epilepsy.

Surgical history-
- Left eye- Cataract surgery 1 year back. 
- Blood transfusions- 2 units of PRBC i/v/o of anemia ( hb - 6.0 ) in Feb 2022

PERSONAL HISTORY:
- Diet- Mixed
- Appetite- Decreased
- Sleep- Adequate 
- Bowel and Bladder habits- Decreased urine output
- Addictions- Consumes  alcohol - 180 ml twice weekly (since 20 years) 
Chews Gutka (since 20 years) 

EXAMINATION:


Patient is conscious, coherant and cooperative, and examined in a well lit room after giving informed consent.

On 9/3/22 (day of admission) 

VITALS
TEMP : 99.2 f
HR : 88 bpm
BP : 130/80 mm hg
RR : 26 cpm
SPO2 : 98 % @ RA
GRBS:  208 mg/dl 

Pallor- seen 
Bilateral pitting edema upto knees seen 

No icterus, clubbing, lymphadenopathy. 

 
CVS : s1, s2 + . No murmurs 
RS : BAE+ NVBS + 
CNS  : NAD
P/A : soft, non tender. 


PROVISIONAL DIAGNOSIS :  Chronic kidney disease with Heart failure with reserved ejection fraction with DM & HTN 

TREATMENT/PATIENT PROGRESS


On 9/3/22

One session of hemo dialysis done 
1.fluid restrictions <1.5L/day.
2.salt restrictions <2g/day
3.TAB.LASIX 40mg BD
4.TAB.ECOSPORIN -AV OD
5.TAB.MET-XL 12.5mg OD
6.TAB.NODOSIS 500MG BD
7.TAB.SHELCAL 500MG OD
8.TAB. BIO-D3 0.25MG OD
9.TAB.OROFER-XT OD
10.inj. HAI sc Acc.to Grbs Tid
11.inj ERYTHROPOIETIN 4000U SC x ONCE WEEKLY

On 10/3/22 

Complaints of tremors + , generalised body pains 
On examination, patient is c/c/c
Bp : 110/70 mm hg
HR : 84.bpm
Cvs : s1 , s 2+ 
Rs : BAE + nvbs + 
CNS : NAD 
PD- CKD with HFREF with DM & HTN 
Patient continued with the same treatment 

On 11/3/22

Patient has Generalised body pains increased, 
intensity of tremors decreased compared to yesterday after dialysis . 
On examination pt is c/c/c
Bp : 120/80 mmhg
HR :  84 bpm 
Cvs : s1 , s 2+ 
Rs : BAE + nvbs + 
CNS : NAD 
PD- CKD with HFREF with DM & HTN 
Patient continued with the same treatment
2nd session of dialysis done. 

On 12/3/22 

Fever spikes are observed (102 f) 
Generalised body pains +
On examination patient is c/c/c
Bp : 120/70 mm hg 
HR : 88 bpm
Cvs : s1 , s 2+ 
Rs : BAE + nvbs + 
CNS : NAD 
PD- CKD with HFREF with DM & HTN 
Patient is continued with the same treatment. 
Added TAB DOLO 650mg TID i/v/o of fever spikes. 

On 13/2/22

Patient has generalised body pains + 
On examination, patient is C/C/C
Bp : 120/80 mm hg
Hr : 92.bpm
Cvs : s1 s2 + 
Rs : BAE +, NVBS
CNS : NAD
PD- CKD with HFREF with DM & HTN 
Patient continued with the same treatment 
Added INJ. NEOMOL IV BD
           INJ.PIPTAZ 2.25 gm iv/TID
3rd session of dialysis done. 

On 14/3/22 

Generalised body pains increased
Fever spikes decreased. 
On examination, patient is drowsy 
Bp : 80/60 mmhg ( i/v/o bp 80/60 mm hg) started on nor adrenaline 6 ml/hr ) 
Hr : 96 bpm 
Cvs : s1 s2 + 
Rs : bae + , nvbs + 
Cns : 
PD- CKD with HFREF with DM & HTN 
Patient is continued on the same treatment
Added inj. TRAMODOL 1amp in 100 ml NS IVX BD
Planned for Lumbar puncture (i/v/o meningeal signs +)
Ophthal referral for fundoscopy (to rule out increased ICP)


Fundoscopy was done now to rule out raised ICT. 
But due to some patient related factors (Brown cataract in right eye and hazy media + anterior chamber hypopyon in left eye) they are not able to clearly visualize optic disc to comment on raised ICT. 


On 15/3/22

Patient has generalised body pains +
On examination, patient is drowsy but arousable 
BP- 90/70 mmHg (Noradrenaline 8ml/hr)
HR- 92 bpm
CVS- s1 s2 +
RS- BAE + NVBS +
CNS- 
PD- CKD with HFREF with DM & HTN 
Patient is continuing on the same treatment
Planning for MRI BRAIN to determine raised ICP


On 16/3/22 

Patient is drowsy but arousable 
BP- 90/60 mmHg (noradrenaline 16ml/hr)
HR- 102 bpm
CVS- s1,s2 +
RS- BAE + NVBS +
CNS- 

Tone  Right Left
Elbow   Hypertonic  Hypertonic
Shoulder Hypertonic Hypertonic
Hips  Hypertonic  Hypertonic
Knee  Hypertonic  Hypertonic
Kernig sign  Positive
Brudzinski sign Positive
Reflexes Right Left
Biceps  2+       2+
Triceps  2+      2+
Supinator  2+      2+
Knee.       -               - 
Ankle.      -              -
Babinski  No response No response 
 Lateral rectus palsy + ( false localizing sign ) 

RFT
Urea- 160
Creatinine- 5.0
Uric Acid- 2.2
PH- 5.5
Na- 146
K- 5.4
Cl- 98

Hemogram
Hb- 9.2
Total count- 19,200
Platelets- 1.78
MCV 86.3

ABG ON ROOM AIR
pH 3.36
Pco2 34.9
Hco3 20.3
Pao2 95.5
Spo2 96.3

PD- CKD with HFREF with DM & HTN with a possibility of meningitis 
Treatment- 1.fluid restrictions <1.5L/day.
2.salt restrictions <2g/day
3.TAB.LASIX 40mg BD
4.TAB.ECOSPORIN -AV OD
5.TAB.MET-XL 12.5mg OD
6.TAB.NODOSIS 500MG BD
7.TAB.SHELCAL 500MG OD
8.TAB. BIO-D3 0.25MG OD
9.TAB.OROFER-XT OD
10.inj. HAI sc Acc. To Grbs Tid
11.inj ERYTHROPOIETIN 4000U SC x ONCE WEEKLY    
INJ. Meropenem 500 mg IV BD
Inj. THIAMINE 1 AMP in 100 ml NS IV BD
INJ. TRAMADOL 1 AMP IN 100 ML NS IV BD
INJ. NEOMOL IV SOS

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