A 73 YEAR OLD MALE PATIENT WITH PEDAL EDEMA, SHORTNESS OF BREATH AND DECREASED URINE OUTPUT.

Y.NAVYA SAHITHI REDDY

ROLL NO 167

2K17 BATCH.

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CASE DISCUSSION

A 73 yr male patient teacher by occupation, resident of .............. presented to Opd with chief complaints of :

PEDAL EDEMA ,SINCE 15 DAYS

SHORTNESS OF BREATH, SINCE 4 DAYS

DECREASED URINE OUTPUT ,SINCE 2 DAYS

HISTORY OF ILLNESS

Patient is chronic alcoholic since 40yrs ( stopped few months back) and non-smoker was apparently asymptomatic 30yrs ago. He was diagnosed with type 2 diabetes mellitus 30yrs back and hypertension 19yrs back on regular checkup. Since then he has been on medication with Tab.Glicazid 80mg BD and since 4 yrs he has been taking human mixtard insulin 15u-0-8u daily for DM and on Tab. Telma H 40/12.5gm, Tab.Prazosin 5mg BD and Tab.Met-xl 50mg BD .

Pedal edema since 4 years associated with exertional dyspnea . On checkup was diagnosed with CKD STAGE 4. Was started on medication with Tab.Dytor 10mg and Tab.Nodosis 500mg BD . He used the medication for 3yrs following which his creatinine levels dropped from 3mg to 2mg . He stopped the medication as his creatinine levels reduced since a year following which he complaints of ON AND OFF pedal edema which has increased significantly since past 15 days.

Blurring of vision , since 4yr ( Diabetic retinopathy).

H/O fever and cough 3 months back .He was tested covid-19 positive and was on medication and in home isolation . He was tested negative after 10 days of illness.

 2 months ago , pt. complaints of spontaneous formation of bleb on 3rd toe of left lower limb. Dressing done by local RMP.

1 month ago ,H/O unresponsiveness and starring look - 1 episode of hypoglycemia. h pt. regained consciousness after administration of iv fluids. attenders claim it to be due to his blurred vision he must have taken high dose of insulin than prescribed dose.

H/O RTA 10 days back causing injury to left lower limb -laceration wound present .dressing done by local RMP, using analgesics.

 SOB since 4 days which progressed from grade 2 to grade 3 associated with orthopnea and PNS, unable to sleep due to sob since 4 days.

decreased urine output since 2days.

No H/O fever , cold , cough, facial puffiness .

PERSONAL HISTORY 

diet - mixed

appetite- normal

bowel and bladder - decreased urine since 2 days

sleep- not able to sleep since 4 days due to sob

addictions- chronic alcoholic since 40 yrs

GENERAL EXAMINATION 

Pt. is C/C/C

well orientated to time , person , place

heavily built with central truncal obesity

pallor- present

No icterus, cyanosis, clubbing , lymphadenopathy

pedal edema -present 

ulcer on left limb following accident

vitals at the time of admission:

temperature- afebrile

pulse rate-73bpm

respiratory rate-28cycles/min

BP- 130/70mmhg , left arm , sitting position

spo2-96 

 PEDAL EDEMA:

SYSTEMIC EXAMINATION:

CARDIO VASCULAR SYSTEM-

S1 S2 heard ,no additional murmurs.

RESPIRATORY SYSTEM

dyspnea - present

wheeze -absent

BAE + 

bilateral diffuse crept being heard

ABDOMINAL EXAMINATION

shape of abdomen- distended

tenderness- absent

palpable mass- not present

free fluid - present ( SHIFTING DULLNESS PRESENT)

 No hepatomegaly and splenomegaly

bowel sound - heard

CENTRAL NERVOUS SYSTEM

pt. is conscious

speech-normal

signs of meningeal irritation- absent

no abnormal defects

reflexes can be elicited

INVESTIGATIONS

CBP , LFT , ABG , ABG , X-RAY CHEST , 2D ECO , USG ABDOMEN, ECG

DAY 3: pt. went LAMA as they can avail ESH in other hospital.

DIAGNOSIS

Heart failure with preserved ejection fraction

Diabetes, hypertension

Left lower limb ulcer

Diabetic triopathy

?Anemia of chronic disease

TREATMENT

Fluid restriction( <1 lit)

salt restriction diet (<2g per day)

Inj. Lasix Infusion 2amp(80mg)+46ml NS @2ml/hr ( 3.2mg/hr)

Tab. Met-xl 50mg PO BD

Tab. Orofex-xt PO OD

Tab.Ecospirin-AV (75/20) night single dose

Protein x powder 2 scoops in glass of milk BD

Tab. Prazosin 5mg PO BD

Tab. Teneligliptin 20mg PO OD

Inj. Human mixtard insulin S.C after informing 8am-2pm-8pm

GRBS 6th hourly ( 8am-2pm-8pm-2am)

Daily dressing for ulcer

Inj. Augmentin 1.2g IV BD

BP /PR monitoring 2nd hrly

Questions for case

1, What are the possible causes for heart failure in this patient?

2, What is the reason for anemia in this case?

3, What is the reason for blebs and ulcer in patient?

4, What sequence of stages of diabetes mellitus has been noticed in the above patient?