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.

This is an online E log book to discuss our patient's   
de-identified health data shared after taking 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 patient's 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 the comment box is welcome.
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?











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