65 year old female with pedal edema and shortness of breath

This is 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 comments on comment box is welcome.

Vignatha 9th semester

roll no: 45

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:

A 65 year old lady from miryalaguda district came to the hospital with the chief complaints of pedal edema since 9 days and shortness of breath since 9 days.

History of present illness:

The Patient was apparently asymptomatic 9 days ago then she developed pedal edema which was of pitting type and she was unable to walk.Her son is an RMP, got her renal function tests done. He noticed a raise in serum creatinine which was 12mg/dl, hemoglobin 7gm/dl. She also had shortness of breath, initially it was of grade 2 and on 31st march it was grade 4.

Past history:

No similar complaints in the past.

She is a known case of diabetes and hypertension since 13 years.

She had a history of fracture of left upper limb. Took ayurvedic treatment. Since then she was unable to do her daily work at home.

There is no history of TB, epilepsy, asthma etc.

Personal history:

Mixed diet

Normal appetite 

Adequate sleep(8-10hours)

Bowel and bladder movements :normal

No addictions 

Family history:

No similar complaints 

General examination:

Consent was obtained. 

The patient was unconscious, not oriented to time, place and person. 

Built: obese

She has pallor, pedal edema.

No icterus, cyanosis,  clubbing and lymphadenopathy. 


Inspection:

There were hypopigmented patches on her limbs and are not associated with itching. 

vitals

Pulse:80 bpm

Temperature: afebrile 

Respiratory rate: 30 cpm

Systemic examination:

Cvs: s1 and s2 heard 

Respiratory system: sob grade 4

Cvs : the patient is unconscious 

Abdomen: soft and non tender 

Investigations:

Complete blood picture:


Hemoglobin:7.7gm/dl

Pcv: 23.6 (normal range:36-46)

Rbc: 2.62 millions/cubicmm

Complete urine examination 

normal

Serum iron:96ug/dl 

HbsAg: negative 

Random blood sugar:180mg/dl

Blood urea:154mg/dl (normal range:17-50)

Serum creatinine:11.4mg/dl (normal range:0.6-1.2)

Serum electrolytes:

Sodium:135mEq/l (normal range:136-145)

Potassium:5.7mEq/l (normal range:3.5-5.1)

Chloride:98mEq/l (normal range:98-107)

Ecg


USG 

colour doppler 2D echo

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

Death summary:

Pt. was gasping for air even with oxygen, so she was intubated and connected to mechanical ventilation since 8am

On 31st march 10am

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.






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