80year old with SOB, pedal edema and generalized weakness

CBBLE UDHC SIMILAR CASES 

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 box.


80 year old female presented with 
  • Increase in Shortness of breath since 3 days 
  • Bilateral pedal edema since 3 days
  • Generalized weakness since 20 days 
  • History of fall 20 days back 
Patient was apparently asymptomatic 20 days back then she suffered trauma due to slipping in the bathroom, she fell in sitting position and complained of left hip pain. 

She could walk normally for 4 days but later complained of too much


pain and was confined to bed. 
She developed of Shortness Of Breath which was insidious in onset. She developed SOB after walking a certain distance since 1 week but on 21/3/22 she had Shortness of breath at rest and was taken to a local hospital where she was put on O2. She improved and was advised to come here. 

H/o COVID 19 infection in April 2021, her symptoms were cold, Shortness of breath and generalized weakness, for which she isolated at home and used medication for 1 week. All her symptoms improved but the weakness took 3 months to subside. 

10 days back, She was unable to recognize her son in laws  and had several episodes of irrelevant speech at inappropriate timings and a few episodes of fear. She was also unable to sleep at night. 
I/V/O these symptoms patient was taken to hospital and a CT scan was done, which didn’t reveal any abnormalities. 

She was diagnosed with Hypertension 20 years back when she had an episode of giddiness associated with loss of consciousness, she received treatment for 3-4 days at the hospital. 

She was also diagnosed with Diabetes Mellitus 13years back when she went for a regular check up.
 
Surgical history: 
Underwent appendectomy 45 years back and hysterectomised 20 years back. 

No history of blood transfusions.
No history of orthopnea/PND.

Personal history: 
Diet: mixed 
Appetite: normal
Sleep: disturbed, unable to sleep at night
Bowel and bladder movement: regular 
Addictions: none 

General examination: 

Patient is conscious, coherent and cooperative. 
She is oriented to place and person but not to time. 
Pallor present. 
No icterus, cyanosis, clubbing, lymphadenopathy. 






B/L PITTING TYPE PEDAL EDEMA 











Vitals on admission: 
Temp: 98.6
PR: 90/min
BP: 120/70 mmHg

CVS: S1 S2 present 
JVP raised 




RS: BAE +
Decreased breath sounds on left side. 
Crepitations heard in left infrascapular area,inframmary area and interscapular area. 

CNS: E4V5M6

P/A: soft, non tender 

Investigations: 
BGT: O positive 

HEMOGRAM: 
Hb: 8.3
TLC: 13,300
N/L/E/M: 79/11/4/6
Plt: 4.37 lakh
PCV: 24.9
MCH: 26.0

Serum Iron: 58
Retic count: 1.8%
Troponin I: negative 

Serology: negative 
RBS:189mg/dl
HbA1c: 6.9%
ESR: 25
CRP: Positive (2.4mg/dl)

LFT: 
Tb: 0.69
DB: 0.20
AST: 798
ALT: 644
TP: 5.8
Alb: 2.88
A/G: 0.99

RFT: 
B urea: 54
S Creat: 1.9
Uric acid: 10.5
Na: 135
K: 4.3
Cl: 98


Chest X-ray: 




X Ray pelvis AP




X ray left thigh lateral: 




ECG 



2D ECHO











USG abdomen





Diagnosis:

RIGHT VENTRICULAR FAILURE WITH PULMONARY ARTERY HYPERTENSION WITH ACUTE HEPATITIS 
WITH DM & HTN 

Treatment: 

1. Tab. ECOSPORIN/AV 75/20 mg OD
2 .Inj. MONOCEF 1gm IV BD
3. Inj. LASIX  20mg IV BD
4. GRBS 6th hourly



https://caseopinionsbyrollno156.blogspot.com/2022/03/80year-old-with-sob-pedal-edema-and.html

NEW ADMISSION
ICU FIRST BED
23/3/22

S: 
B/L pedal edema 
Generalized weakness 

O: 

Temp: 98.3
PR: 89
RR: 22
BP: 
CVS: S1 S2 present 
JVP raised 
RS: BAE +
Decreased breath sounds on left side. 
Crepitations heard in left infrascapular area,inframmary area and interscapular area. 

CNS: E4V5M6

HEMOGRAM: 
Hb: 8.3
TLC: 13,300
N/L/E/M: 79/11/4/6
Plt: 4.37 lakh
PCV: 24.9
MCH: 26.0

Serum Iron: 58
Retic count: 1.8%
Troponin I: negative 

Serology: negative 
RBS:189mg/dl
HbA1c: 6.9%
ESR: 25
CRP: Positive (2.4mg/dl)

LFT: 
Tb: 0.69
DB: 0.20
AST: 798
ALT: 644
TP: 5.8
Alb: 2.88
A/G: 0.99

RFT: 
B urea: 54
S Creat: 1.9
Uric acid: 10.5
Na: 135
K: 4.3
Cl: 98

A: 
RIGHT VENTRICULAR FAILURE with PULMONARY ARTERIAL HYPERTENSION WITH ACUTE HEPATITIS 
WITH DM & HTN 

P:

1.Tab. ECOSPORIN/AV 75/20 mg OD
2. Inj. MONOCEF 1gm IV BD
3. Inj. LASIX  20mg IV BD 
4. GRBS 6th hourly



https://caseopinionsbyrollno156.blogspot.com/2022/03/80year-old-with-sob-pedal-edema-and.html
AMC 3rd bed 
24/3/22

S: 
B/L pedal edema 
Generalized weakness 

O: 

Temp: 98.5°F
PR: 92bpm
RR: 20 cpm
BP: 140/70 mmHg
CVS: S1 S2 present 
JVP raised 
RS: BAE +
Decreased breath sounds on left side. 
Crepitations heard in left infrascapular area,inframmary area and interscapular area. 

CNS: E4V5M6

HEMOGRAM: 24/3/22
Hb: 8
TLC: 9,80
N/L/E/M: 70/16/4/10
Plt: 3.22 lakh
PCV: 24
MCH: 26.1

A: 
RIGHT VENTRICULAR FAILURE with PULMONARY ARTERIAL HYPERTENSION WITH ACUTE HEPATITIS 
WITH DM & HTN 

P:

1.Tab. ECOSPORIN/AV 75/20 mg OD
2. Inj. MONOCEF 1gm IV BD (D2)
3. Inj. LASIX  20mg IV BD 
4. GRBS 6th hourly

Pedal edema on 24/3/22 



Ophthalmology referral done I/V/O Cataract


Orthopaedic referral I/V/O Left hip pain

https://caseopinionsbyrollno156.blogspot.com/2022/03/80year-old-with-sob-pedal-edema-and.html
Ward case 
25/3/22

S: 
Left hip pain (decreasing) 
B/L pedal edema 
Generalized weakness 

O: 

Temp: 98.5°F
PR:  107bpm
RR: 16 cpm
BP: 120/70 mmHg
CVS: S1 S2 present 
RS: BAE +
Decreased breath sounds on left side. 
Crepitations heard in left infrascapular area,inframmary area and interscapular area. 

CNS: E4V5M6

24/3/22
Sr creatinine 1.0
Sr urea 34

LFT
TB: 0.68
DB: 0.18
AST: 156
ALT: 328
ALP: 168
TP: 5.5
Alb: 2.5
A/G: 0.84


25/3/22

Sr. Creatinine 1.1
Blood urea 27

LFT 
TB: 0.61
Db: 0.16
AST: 79
ALT: 221
Alk P: 194
TP: 5.1
Albumin: 2.6
A/G: 1.08 


A: 
RIGHT VENTRICULAR FAILURE with PULMONARY ARTERIAL HYPERTENSION WITH ACUTE HEPATITIS 
WITH DM since 13 years & HTN since 20 years 

P:

1.Tab. ECOSPORIN/AV 75/20 mg OD
2. Inj. MONOCEF 1gm IV BD
3. Inj. LASIX  20mg IV BD 
4. GRBS 6th hourly
5. Tab. METFORMIN PO OD (8PM)
6. Tab. CILNIDIPINE 10mg PO OD
7. Tab. GLIMI M1 PO/OD
8. INJ. ZOFER 4mg IV TID 
9. I/O charting
10. Vitals monitoring 4th hourly

https://caseopinionsbyrollno156.blogspot.com/2022/03/80year-old-with-sob-pedal-edema-and.html
Ward case 
27/3/22
S: 
B/L pedal edema decreased 
Left hip pain decreased 

O: 

Temp: 98.5°F
PR: 92bpm
RR: 19 cpm
BP: 130/70 mmHg
CVS: S1 S2 present 
RS: BAE +
Decreased breath sounds on left side. 
Crepitations heard in left infrascapular area,inframmary area and interscapular area. 

CNS: E4V5M6

A: 
RIGHT VENTRICULAR FAILURE with PULMONARY ARTERIAL HYPERTENSION WITH ACUTE HEPATITIS 
WITH DM since 3 years & HTN since 20 years  

P:

1.Tab. ECOSPORIN/AV 75/20 mg OD
2. Inj. MONOCEF 1gm IV BD
3. Inj. LASIX  20mg IV BD (8 AM and 8 PM)
4. GRBS 6th hourly
5. Tab. METFORMIN 500mg PO BD 
6. Inj. ZOFER 4mg IV TID 
7. Tab. RAMIPRIL 2.5mg PO OD 
8. Tab. GLIMI M1 PO OD 
9. Vitals monitoring 4th hourly

https://caseopinionsbyrollno156.blogspot.com/2022/03/80year-old-with-sob-pedal-edema-and.html
Ward case 
28/3/22
S: 
B/L pedal edema decreased 
Left hip pain decreased 

O: 

Temp: 98.5°F
PR: 96bpm
RR: 20 cpm
BP: 110/70 mmHg
CVS: S1 S2 present 
RS: BAE +
Decreased breath sounds on left side. 
Crepitations heard in left infrascapular area,inframmary area and interscapular area. 

CNS: E4V5M6

A: 
RIGHT VENTRICULAR FAILURE with PULMONARY ARTERIAL HYPERTENSION WITH ACUTE HEPATITIS 
WITH DM since 3 years & HTN since 20 years  

P:

1.Tab. ECOSPORIN/AV 75/20 mg OD
2. Inj. MONOCEF 1gm IV BD
3. Inj. LASIX  20mg IV BD (8 AM and 8 PM)
4. GRBS 6th hourly
5. Tab. METFORMIN 500mg PO BD 
6. Inj. ZOFER 4mg IV TID 
7. Tab. RAMIPRIL 2.5mg PO OD 
8. Tab. GLIMI M1 PO OD 
9. Vitals monitoring 4th hourly




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