65 YEAR OLD FEMALE WITH PEDAL EDEMA AND SHORTNESS OF BREATH

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Name: Sreshta J

Roll no: 48

I've 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, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION

A 65-year-old female has presented to us on 29 March 2022 with the chief complaints of

• Pedal oedema for 9 days
• Shortness of breath (SOB hereafter) for 9 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 9 days ago then she developed swelling of the lower limbs. She also complained of weakness and SOB. Her son who is an RMP got RFT done and her creatinine was elevated to 12mg/dl (normal is 0.6-1.2mg/dl). He then brought her to our tertiary care hospital for treatment.

PEDAL EDEMA: 

• It was sudden in onset
• Extending up to the knees
• Pitting type

WEAKNESS: 

• It was insidious in onset.
• She couldn't walk at all.
• no h/o trauma or seizures.

SOB:

• She had grade 2 SOB which progressed to grade 5

PAST HISTORY :

• no similar complaints in the past.
• h/o left upper limb fracture due to fall on outstretched hand 2 months ago. Took ayurvedic treatment. 
• known case of diabetes and hypertension for 13 years and has been on medication since
• not a known case of asthma, epilepsy, TB.

PERSONAL HISTORY :

• normal appetite
• takes vegetarian diet predominantly
• bowel movements: constipation for 2 months
• micturition is normal
• no known allergies

No similar complaints in the family.

GENERAL EXAMINATION:

Done after obtaining consent from the patient's attender. The patient is unconscious and not oriented to time, place, person.

• She has pallor, Pedal oedema which is of pitting type
• No icterus, Cyanosis, Koilonychia, Generalised Lymphadenopathy and clubbing

Pedal oedema youtube link: https://youtube.com/shorts/89rIzF45Jbk?feature=share 

She also had hypopigmented spots on the skin for 35 years. There's no itching 

VITALS:

• Temperature - afebrile
• Pulse rate- 80 bpm
• BP- hypotension
• Respiratory rate- 30 cpm

SYSTEMIC EXAMINATION:

1. CVS: S1 & S2 heard

2. Respiratory system: SOB- grade 5

Youtube video link: https://youtube.com/shorts/9EO4egOdnDw?feature=share

3. Abdomen: Soft and non-tender

4. CNS:

• She was unconscious. 
• Glasgow come score: E1 M1 V1

INVESTIGATIONS:

CBP

• Haemoglobin- 7.7 gm/dl (12-15 gm/dl is normal)
• PCV- 23.6 vol% (36-46 vol% is normal)
• RBC- 2.6 million/cubic mm (4.5-5.5 million/cubic mm is normal)

RBS- 180 mg/dl (100-160 mg/dl is normal)

BLOOD UREA- 154mg/dl (17-50 mg/dl is normal)

SERUM CREATININE- 11.4 mg/dl (0.6-1.2 is normal)

SERUM ELECTROLYTES

• sodium- 135 mEq/L (136-145 mEq/L is normal)
• potassium- 5.7 mEq/L (3.5-5.1 mEq/L is normal)

ECG

USG

COLOR DOPPLER

PROVISIONAL DIAGNOSIS:

This is a case of Diabetic Nephropathy

TREATMENT: 

TAB. Lasix 40 mg PO/BD 

2) TAB. Nodosis 500 mg PO/BD 

3) TAB. Shelcal CT 500 mg PO / OD 

4) TAB. Orofer XT 1 tab PO /OD 

5) TAB. PAN 40 mg PO/OD 

6) INJ. Erythropoietin 4000 IU SC. Weekly once

7) TAB. Nicardia 20 MG PO/TID

31 MARCH 2022- DEATH NOTES

Pt. was gasping for air even with oxygen, she was intubated and connected to mechanical ventilation.

ECG- 

• taken at 10 am. 
• Shows ST segment depression in leads 2, v5 & v6. Lead avr shows ST elevation

ABG- Acidosis

• pH-         6.76 (7.35-7.46 is normal)
• pCO2-    123 mmHg (35-45 is normal)
• pO2-     112 mmHg (80–100 mm of mercury is normal)
• HCO3- 16.4 mEq/L (<18 mEq/L is acidosis)
• K-          8.2 mEq/L (3.5-5.1 mEq/L is normal)

10.35am

is Pt. had sudden onset bradycardia and asystole for which CPR was initiated

• 10.35 am - no pr/bp-cpr initiated-inj adrenaline 1 cc iv /stat 10:40 am-no pr/bp-cpr continued-inj adrenaline 1 cc iv stat
• 10:45 am-no pr /bp cpr continued inj adrenaline 1 cc iv/stat
• 10,50 am-no pr /bp cpr continued inj adrenaline 1 cc iv /stat) 10:55 am-no pr /bp cpr continued inj adrenaline 1 cc iv /stat
• 11:00 am-no pr /bp cpr continued inj adrenaline 1 cc iv /stat
• 11:05 am-no pr /bp
• Inspite of the above resuscitation measures patient could not be revived and declared dead at 11.07 am on 31/3/22
• Immediate cause of death: cad? nstemi/posterior wall mi, type 2 respiratory failure, refractory hypotension, uremic encephalopathy 
• Antecedant cause of death: chronic renal failure, copd, type 2 dm, htn