PREFINAL: A 67yr old male with Shortness of breath and pedal edema

 🍁Greetings to one and all going through my E log!! 

🩺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 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. 

I am Nomika Alli (Roll no 179) of 9th Sem MBBS. 

A 67 year old Male R/O Devarakonda , came to the casualty on 2nd December 2023 with complaints of Shortness of breath since 10 days and pedal & facial  edema since 8 days 

HISTORY OF PRESENT ILLNESS:

Patient  came in drowsy but arousable state to the casualty . He was apparently asymptomatic 10 days back , then he developed Shortness of breath which is insidious in onset, gradually progressive in nature, aggravating on exertion and relieved on taking rest, progressed from grade II to grade III- IV (Modified MRC) 

Orthopnea, Paroxysmal nocturnal dyspnea present

C/O Bilateral pedal edema below knees , facial puffiness and periorbital edema since 8 days , insidious onset, gradually progressive in nature , no diurnal variation, pitting type I.

C/o decreased urine output and decreased appetite since 5days 

No C/o chest pain, palpitations, profuse sweating,

No c/o fever, cold, cough, nausea, vomiting, loose stools.

His daily routine is waking up at 6: 00 am, breakfast as idli/upma at 8:00 am . He used to have his lunch as rice and curry , sambhar/rasam at 1: 00 pm .He usually haves his dinner as chapati/upma/rice and curry at 8:00pm and goes to bed by 9:00 pm.

The patient used to lead a normal life before this 15days .

HISTORY OF PAST ILLNESS:

K/c/o asthma since 10yrs -on medication

N/K/C/O DM, CAD, CVD, Thyroid, epilepsy

K/C/O HTN 6 yrs ago and used medication for 3 yrs and stopped as BP was under control

H/O TB 30 yrs ago

SURGICAL HISTORY: -

FAMILY  HISTORY: 

N/K/C/O DM, HTN, Asthma, Epilepsy, CAD, CVD, TB, Thyroid

PERSONAL HISTORY:

Married

Shop keeper by occupation

Diet: Mixed

Appetite: decreased

Sleep: adequate

Urine output decreased

Bowel movements: Regular

Addictions: Alcohol occasionally

Allergies: no known

GENERAL EXAMINATION: 

Patient is drowsy due to sedation, coherent to time , place, person.

Ht: 155cm      Wt: 58 kg

Pallor: present 

Icterus: absent

Clubbing: absent

Cyanosis: absent

Koilonychia: absent

Lymphadenopathy: absent

Post intubation vitals: Vitals: Temp: 98 F

BP: 90/60 mmHg

PR: 102 bpm

RR: 15 cpm ACMV mode

SpO2: 100% at 5 litre O2

GRBS: 126 mg%

SYSTEMIC EXAMINATION:

RS:

Orthopnea +

Paroxysmal nocturnal dyspnoea +

wheeze +

Central position of trachea

NVBS +

CVS:

S1 S2 heard

No murmurs

No thrills

ABDOMEN:

Shape of abdomen: mildly distended

No tenderness

No palpable mass

No bruits

Liver and spleen- not palpable

Bowel sounds heard

CNS:

drowsy but arousable 

no neck stiffness

kernig's sign negative

cranial nerves: normal

motor - intact

sensory - intact

Glasgow scale E2V2M2 = 6/15

MUSCULOSKELETAL SYSTEM: normal

SKIN: normal

ENT: normal

TOOTH & ORAL CAVITY: normal

PHYSICAL EXAMINATION:

muscle wasting++

PROVISIONAL DIAGNOSIS:

 Altered sensorium ? AKI ??

HEART FAILURE(ET 51%)

ANAEMIA

INVESTIGATIONS: 

2-12-23

RFT raised urea, creatinine, uric acid, phosphorus,

V

ABG

TROPONIN ↑

BLOOD UREA ↑↑

S. Creatinine ↑ ↑

potassium ↑

 blood sugar↑

LFT: AST, Alkaline phosphatase, total proteins↑

RFT: Urea, creatinine, phosphorus, potassium ↑

USG

ECG: Left ventricular hypertrophy

MRI Brain plain

The patient may be having (from investigations)

UREMIC ENCEPHALOPATHY 

AKI ON CKD 

HEART FAILURE EF 51%

Anemia secondary to CKD

TREATMENT:

intubated i/v/o respiratory failure & low GCS

IV fluids NS @50ml/hr

Ryles feeds water 50ml 2hrly milk 100ml 3hrly

Inj. midazolam 30ml= Inj. Fentanyl 

Inj. Noradrenaline 2amp 

Inj. Piptaz 2.25ml IV/TID

ET Tube suction 2hrly

chest physiotherapy 

position change 2hrly

monitor vitals hrly

Tab. Aspirin 

Tab. atorvastatin

3-12-23

APTT

PT

Hemogram: low HB , lymphocytes, eosinophils, PCV, RBC count

raised total count, neutrophils

BT& CT

ABG

RFT: Raised urea, creatinine

ECG

The patient may be having (from investigations)

UREMIC ENCEPHALOPATHY 

AKI ON CKD 

HEART FAILURE EF 51%

Anemia secondary to CKD

TREATMENT:

intubated i/v/o respiratory failure & low GCS

IV fluids NS @50ml/hr

Ryles feeds water 50ml 2hrly milk 100ml 3hrly

Inj. midazolam 30mg+ Inj. Fentanyl 200mcg @16mg/hr

Inj. Piptaz 2.25gm IV/TID

ET Tube and oral suction hrly

Tab. Nodosis 500mg

chest physiotherapy 

position change 2hrly

monitor vitals hrly

Tab. ecosprin  75mg RT/OD

Tab. atorvastatin 20mg

4-12-23

2D ECHO:

• No RWMA, paradoxical IVS
• trivial MR, Mild AR
• mild to moderate TR with PAH
• Sclerotic AV, no AS/MS, IAS- intact
• EF= 51 RVSP2 48mmHg
• Good LV systolic function
• diastolic dysfunction
• mild PE(+)
• IVC size 1.20cm collapsing

ABG

Hemogram: low HB , lymphocytes, PCV, RBC count

raised total count, neutrophils 

RFT :Urea, creatinine raised

ECG

The patient may be having (from investigations)

UREMIC ENCEPHALOPATHY ??

AKI ON CKD 

HEART FAILURE EF 51%

Anemia secondary to CKD

TREATMENT:

intubated i/v/o respiratory failure & low GCS

IV fluids NS @50ml/hr

Ryles feeds water 50ml 2hrly ,milk 100ml 3hrly

Inj. midazolam 30mg+ Inj. Fentanyl 

Tab. Nodosis 1gm 

Inj. Piptaz 2.25ml IV/TID

ET Tube and oral suction hrly

chest physiotherapy 

position change 2hrly

monitor vitals 4 hrly

I/O charting

Tab. ecosprin 75mg

Tab. atorvastatin 20mg

Inj. lasix 40mg

Inj.KCl 40mcg in 500ml/NS

5-12-23 

ABG

ECG

The patient may be having (from investigations)

UREMIC ENCEPHALOPATHY ??

AKI ON CKD 

HEART FAILURE EF 51%

Anemia secondary to CKD?

TREATMENT:

intubated i/v/o respiratory failure & low GCS

IV fluids NS & DNS@50ml/hr

Ryles feeds water 50ml 2hrly ,milk 100ml 3hrly

Inj. Piptaz 2.25ml IV/TID

Inj. sodium bicarbonate 20ml/IV/TID

ET Tube and oral suction 2hrly

monitor vitals  hrly

I/O charting

Tab. ecosprin 75mg

Tab. atorvastatin 20mg

Inj. lasix 40mg

Inj. KCl 40mcg in 500ml/NS

Tab. shelcal ct

Tab. orofer xt

12

6-12-23

Hemogram: low Hb, lymphocytes, eosinophils, PCV, RDC count

RFT: raised urea, Creatinine

ABG

The patient may be having (from investigations)

UREMIC ENCEPHALOPATHY ??

AKI ON CKD 

HEART FAILURE EF 51%

Anemia secondary to CKD?

TREATMENT:

intubated i/v/o respiratory failure & low GCS

IV fluids NS & DNS@50ml/hr

Ryles feeds water 50ml 2hrly ,milk 100ml 3hrly

Inj. Piptaz 2.25ml IV/TID

Inj. sodium bicarbonate 20ml/IV/TID

ET Tube and oral suction 2hrly

monitor vitals  hrly

position changing 2hrly

I/O charting

Tab. ecosprin 75mg

Tab. atorvastatin 20mg

Inj. lasix 40mg

Inj. KCl 40mcg in 500ml/NS

Tab. shelcal ct

Tab. orofer xt

inj. pantop 40mg

inform sos

References: