A 70 YEAR OLD MALE WITH SHORTNESS OF BREATH AND PEDAL EDEMA

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 THIS IS AN 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

                 CASE REPORT:- 

A 70-year-old male patient presented to the casualty with the 


CHIEF COMPLAINTS:- 

S.O.B since 15 days 

loss of appetite for 15 days

decreased urine output since 10 days

pedal edema for 10 days 


HISTORY OF PRESENTING ILLNESS:-


He was apparently asymptomatic 14 years back then he suddenly developed slurred speech and was moving with an abnormal gait then he was taken to a neurosurgeon where he was managed conservatively for a week and was on medication for 4 years. ( medication unknown, indication unknown)( possibly stroke??).

Then after 4 years he was having severe SOB and was taken to a hospital where he was diagnosed with COPD and the medication dose was decreased and his symptoms subsided.

In 2018, then he had a traumatic injury to the leg which was not healing and was taken to the hospital where a routine check-up was done to find to have Type 2 DM.

Then in 2021, he developed bilateral pedal edema and on investigations, it was found that CREATININE was high and diagnosed as CKD

Now he presented with the  SOB for 10-15 days. Grade 4 since 3 days. i.e.,( SOB on rest 

not associated with palpitations, sweating

(cough??

loss of appetite for 15 days

decreased urinary output since 10 days

No history of hematuria, or burning micturition. 

Bilateral pitting type of pedal edema since 10 days

he was taken to a local hospital where they found to have higher creatinine and was sent here for further management.

TIMELINE OF EVENTS:-




PAST HISTORY:- 

HTN for 14 years and on medication since then

( drug dose unknown)

DM for 4 years and on medication ( drug and dose unknown

known case of CKD since 2 years

no history of TB, Asthma, CAD, or leprosy.


PERSONAL HISTORY:-

Diet - mixed

appetite - decreased

bowel and bladder - Regular

sleep - adequate

Addictions - smoked for 15 years and stopped smoking after being diagnosed with COPD in 2012.

occasionally alcohol


No surgeries done in the past.



FAMILY HISTORY:- 

No relevant family history


ALLERGIC HISTORY:- 

no allergies to any kind of drugs and food.


GENERAL EXAMINATION:- 

the patient was semi-conscious and is on the ventilator 

not well nourished and weakly built.




VITALS:- 

Temperature:- febrile

P.R:- 100

R.R:- 24

BP:- not measured

GRBS:- 177mg%









PALLOR  

Icterus 

No cyanosis 

No clubbing

No lymphadenopathy

pitting type of edema (bilateral)



SYSTEMIC EXAMINATION:-


RESPIRATORY SYSTEM:-


INSPECTION:-

Anteroposterior diameter increased

on inspection and palpation:- Trachea is central

AUSCULTATION:-

Bilateral air entry present.


FINE CREPTS are heard on 4 areas

right and left infra axillary

and right and left infra scapular.


CARDIO VASCULAR SYSTEM:-

S1 and S2 heard 

No Murmurs heard


Per abdomen:-

the shape of the abdomen:- Scaphoid

no tenderness

no palpable organs

bowel sounds - present


CENTRAL NERVOUS SYSTEM:-


the patient is semi-conscious.


Signs of meningeal irritation:- 

NEGATIVE


cranial nerves - not done as he is on ventilation

sensory system - not done

motor system - not done



INVESTIGATIONS:-



Random blood sugar on 31/7/22:-



ULTRASOUND on 31/7/22:- 



LFT on 31/7/22:-



RFT on 31/7/22:-



Serum Iron on 31/7/22:-



HEMOGRAM On 31/7/22:-



BLOOD GROUPING:-



SEROLOGY:-





ABG on 31/7/22:-



X-ray on 31/7/22 at 10:46 am



ABG on 1/8/22:- 



ECG on 1/8/22:-




RFT on 1/8/22:-



LFT on 1/8/22:- 



X-ray on 1/8/22 on 3:06 am 



X-ray on 1/8/22 on 12:25 pm



ABG on 2/8/22:-




X-ray on 2/8/22 at 7:11 am


ABG on 3/8/22 :- at 8:00 am


Blood urea on 3/8/22:-


Haemogram on 3/8/22:- 


Serum creatinine on 3/8/22:-


Serum electrolytes on 3/8/22:-


ABG at 3:00 am :-


ABG at 5:30 pm :-


ABG at 4/8/22:-6:00am


RFT on 4/8/22:-


5/8/22:-



DIAGNOSIS:-


Acute exacerbation of COPD, CKD secondary to diabetic nephropathy, Anemia of chronic disease HTN since 14 years Type 2 DM since 4 years.


PLAN OF CARE:- Supportive management 


TREATMENT:-

1) Fluid restriction less than 2L/day

2)Salt restriction 

3) NEB - DUOLIN 8 th hourly

                BUDECOID 12 hrly

4) I.V PIPTAZ 2.25 gm IV BD 

5) I.V PAN 40 mg BD 

6)LASIX 60 mg IV BD

7) HYDRO CORTI 100 mg

8) INJ NEOMOL 1g IV

9)INJ LEVOFLOX 

10)INJ ERYTHROPOIETIN 4000 IU 

11) T Shelcal 500 mg

12)NODOSIS 500 mg

13) GRBS charting 6 th hourly

14) vitals charting 4 th hourly

DEATH CERTIFICATE:-

5/8/22:-




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