65 year old female with Shortness of Breath, Bilateral Pedal Edema

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60 year old female house wife, resident of chouttuppal came to casualty with chief complaints of breathlessness since 3 days, pedal edema since 1 month.

Patient was apparently asymptomatic 20 years back , then she developed DM, hypothyroidism and was on regular medication since then.Pt has H/O SOB on and off since 6 months which was initially of grade 2 then progressed to grade 4 since then for which she visited cardiologist in our hospital and is on Aspirin , Atorvas, Clopidogrel since then .Patient developed pedal edema pitting type since 1 month which gradually progressed to anasarca.

She developed severe episode of sob for which she visited a local doctor and managed conservatively.

On Jan 15th , patient had 1 episode of sudden loss of consciousness and was taken to a local hospital and from there she was referred to another hospital.On the way to the hospital, pt had an episode of involuntary micturition and sob and LOC( regained consciousness after 1 hr)associated with involuntary movements for which she was admitted and discharged after 3 days. 

Since yesterday morning patient developed SOB admitted in a local hospital and suffered a cardiac arres at 8:30pm (documented as cardiac arrest,no resuscitation notes available) after 15min she regained consciousness & complained of pain abdomen) and referred to our hospital.

Patient now complains of pain abdomen since 1 day and patient hasn’t passed stools since 5 days.

PAST HISTORY:

Not a k/c/o DM , HTN , epilepsy, asthma , CAD , CVD,TB

Hysterectomy 20 years ago.

PERSONAL HISTORY:

Appetite-Decreased 

Diet - Mixed

Bowel - Regular

Bladder -Regular 

Sleep - Decreased.

General examination:

Patient is drowsy, coherent, cooperative, well oriented to time , place and person 

Pallor - present 

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - pitting type extending till knee 

VITALS : Temp - 98.6 F

                  PR - 86 bpm

                  BP - 120/70 mmHg

                  RR - 36 cpm

                  SPO2 - 76% onRA

                  GRBS - 102 mg/dl

Systemic examination: 

RESPIRATORY SYSTEM:

Inspection:

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: 

Resonant bilaterally 

Auscultation:

Bilateral air entry present. Normal vesicular breath sounds heard.

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest is elliptical.

No raised JVP

No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

Apex beat - felt at left 5th intercostal space

No thrills and parasternal heaves

Auscultation :

S1 and S2 heard. 

PER ABDOMEN:

Inspection :

Umbilicus is central and inverted

All quadrants are moving equally with respiration 

No scars , sinuses , engorged veins, visible pulsations .

Hernial orifices are free.

Palpitation :

Abdomen is soft and non tender .

No organomegaly.

Percussion :

Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM:

On the day of presentation 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes Right Left

Biceps ++ ++

Triceps ++ ++

Supinator ++ ++

Knee ++ ++

Ankle ++ ++

Ulcer over the left lower limb:

Ankle           ++        ++

Ulcer over the left lower limb:

CXR :

INVESTIGATIONS:

23/1 /23

On 24/1:

On 25/1:

27/1/2023

Treatment:

Intermittent CPAP 4th hrly 

INJ PIPTAZ 2.25 gm IV/TID

INJ CLINDAMYCIN 600mg IV/TID

INJ LASIX 60mg IV/BD

INJ HAI SC BEFORE FOOD TID ACC TO BREAKFAST 

TAB ECOSPIRIN AV 75 /20 PO /HS

TAB THYRONORM 100 mg PO/OD

TAB CARVEDILOL 3.125 mg PO/OD

TAB CHYMEROL FORTE PO/TID

VITALS MONITORING