70yrs female with SOB

 70 years with SOB from 10days

 This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients' clinical problems with the 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 are welcome. 

 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, and investigations, and come up with a diagnosis and treatment plan.

CASE PRESENTATION

Patient came to the casualty with the complaints of breathlessness since since 10 days 

Complaints of swelling of both the legs since 10 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days back then she had fever for 1 day which is high grade, sudden onset, associated with chills and rigors, relieved by taking medication. SOB (grade-II) since 10 days which is gradually progressive and Progressed to grade-IV. No orthopnea, No PND.

C/o pedal Edema which is pitting type. 

C/o itchy scaly lesion dorsum of foot since 1 year. 

H/o Burning micturition for 3 days.

No H/o decreased urine output. 

No H/o cough, cold

No H/o chest pain, palpitations

No H/o abdominal pain, nausea, Vomiting, loose stools

PAST HISTORY:

K/C/O HTN since 4 years

Not a K/C/O DM, TB, Epilepsy, CVA, CAD

PERSONAL HISTORY:

Takes mixed diet, normal appetite

Sleep adequate 

Burning micturition since 2 days

Addictions: Drinks Whisky 90ml everyday.

Stopped 10 days back

No Significant Family History

O/E: 

Patient is conscious, coherent, cooperative. Moderately build and nourished

Mild Pallor+

No signs of icterus, cyanosis, clubbing, lymphadenopathy.

Edema of feet present 

Vitals:

Temp: 98.8F

BP: 180/100mmhg ---> 150/100mmhg---130/100mmhg

PR: 100bpm

RR: 32cpm

Spo2: 85% at RA

GRBS: 111 mg/dl

CVS: 

Inspection : no scars, sinuses, engorged veins . 

Apex beat not visible.

Palpitations: 

No temperature rise or no tenderness

no swellings , no pulsations ,heaves or thrill in pulmonary, aortic, tricup and mitral areas.

Apex beat felt at intercostal spaces 5 at mid clavicular line medial side.

Auscultation:S1 S2 heard, No murmurs 

RS:

 Inspection: chest shape : bilaterally symmetrical elliptical 

Movement : bilaterally symmetrical

No scars , sinuses , engorged veins 

Trachea appears to be central

Palpation: No rise in temperature and no tenderness , Apex beat felt at 5 intercostal spaces.

Expansion of chest is bilateral symmetrical in anterior, apical and posterior areas.

Trachea location central .

Tactile vocal fremetus : resonant in all areas 

Percussion: All areas appears are resonant.

Auscultation:BAE present, No added sounds

P/A: soft, non tender, bowel sounds heard

CNS: NFND

INVESTIGATIONS:

RBS- 108mg/dl

Blood Urea- 163mg/dl

S. Creatinine - 5.6mg/dl

USG Abdomen findings -

- Moderate B/L pleural effusion

- Raised echogenicity of B/L kidneys

- Right simple renal cortical cyst

DIAGNOSIS:

CAD - NSTEM

HFPEF (60%)

Non oliguric AKI secondary to CHF (?cardio- renal syndrome)

B/L pleural effusion 

? Eczema secondary to varicose veins

nummular eczema

? COPD

K/C/O HTN since 4years 

TREATMENT:

-Inj. Sodium bicarbonate 50mEq IV STAT for 10-15 mins

-Inj. Sodium bicarbonate 50mEq IV STAT in 100ml NS

-Inj. Lasix 40mg PO BD

-Inj. Heparin 4000IU IV QID

-Inj. Neomol 1gm IV SOS

- Tab. Ecosprin Gold 75/20/75 PO HS

- Tab. Cardivas 3.125mg PO OD

- Tab.Isosorbide nitrate + Hydralazine 20mg+37.5mg PO/OD

- Tab. Nicardia 20mg PO STAT

- Tab. Cinod 10mg PO OD

- IV Fluids @ 75ml/hr

-Tab. NODOSIS 500mg PO/BD

-Liquid Paraffin L/A BD

-Momate cream L/A OD

-T. Teczine 5mg PO/SOS

-T. Dolo 650mg PO/TID

- Nebulization with Salbutamol 6th hourly

Final Diagnosis: hypovolemicshock due to secondary gastritis