58 yr/M with pedal edema & sob since 4 days

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CBBLE UDHC Similar case



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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."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

58 yr old male,  farmer by occupation,  came with the chief complaints of 
B/L pedal edema, sob since 4 days
Fever & cough since 2 days. 

Patient was apparently asymptomatic 3 years ago then he noticed poor wound healing for which he consulted a local doctor and was diagnosed with diabetes mellitus and was on a OHA. since then. 
---- 6 months ago he had a hstory of giddiness for which he consulted a doctor and was diagnosed with hypertension and using the antihypertensives. 
---- 5 months ago he developed bilateral pitting type of pedal edema which was on and off , aggravated on working, subsided by taking rest . 
----3 months ago  he had a history of recurrent generalized body pains which were Dragging type , aggravated on working ,and relieved with medication ? NSAIDS.  
----Then on 14/2/2022  He had a H/O s o b grade 4 , orthopnea, 
H/O bilateral pedal edema which is pitting type up to ankles,  which is associated with periorbital edema , 
H/ o  decreased urine output,  
H/o  decreased appetite, Vomitings( non bilious, non projectile , food as content )  for which he was taken to a hospital in Miryalaguda and was diagnosed as CKD (serum creatinine 9.1 mg/dl)  with anaemia (HB 5.8 , normocytic hypochromic) with pulmonary edema with uremic gastritis 
and was referred to KIMS 
patient got admitted in our hospital on
 19/2/ 2022 .  Here he was diagnosed to have lateral wall STEMI , ACUTE LVF, CKD.  patient was managed symptomatically and five sessions of dialysis  were done with 2 units of PRBC  transfusion . and got discharged on 24/2/2022

ecg on 19/2
 x ray on 19/2/22 

Now on March 8 2022 he came with the complaints of bilateral pedal edema , sob, decreased urine output , facial puffiness, Since 4 days
 fever and cough Since 2 days
 H/O BILATERAL PEDAL EDEMA  which is pitting type, Up to the knees. 
H/O SOB   , which aggravated on  working and relieved with rest 
No h/o chest pain , palpitations , PND. 
H/O DECREASED URINE OUTPUT and facial puffiness
 NO H/O hematuria , Loin pain, thin urine stream , 
 H/O  FEVER which is low grade , not associated with chills and Rigors
 No H/O  headache , blurring of vision ,  vomiting,Diarrhoea,Nasal discharge, burning micturition , 
DRY COUGH  Insidious in onset,  Gradually progressive , No positional and diurnal variation
PAST HISTORY :
 MEDICAL - 
k/c/o Diabetes mellitus type 2 since 3 years and on OH
K/C/O of HTN since 6 months &  on regular  medication  
N/k/c/o Bronchial asthma ,  TB, THYROID DISORDERS, CVA, EPILEPSY. 
PAST SURGICAL : 
left eye -  cataract surgery 1 year back. 
 Previous BLOOD TRNASFUSIONS: 2 units of PRBC i/v/o of anemia ( hb - 6.0 ) in feb 2022

 PERSONAL HISTORY  : 
DIET  : mixed
 Appetite :  decreased
 sleep :  adequate 
bowel  and bladder habits :  decreased urine output
 Addictions : consumes  alcohol -  180 ml twice weekly ( since 20 years) 
Chews Gutka (since 20 years) 

EXAMINATION : Pt is c/c/c
VITALS : 
TEMP : 99.2 f
HR : 88 bpm
BP : 130/80 mm hg
RR : 26 cpm
SPO2 : 98 % @ RA
GRBS:  208 mg/dl 

Pallor + 
B/l pitting edema upto knees. 

No icterus, clubbing, lymphadenopathy. 

 
CVS : s1, s2 + . No murmurs 
RS : bae + NVBS + 
CNS  : NAD
P/A : soft,non tender. 



On 9/3/22



PROVISIONAL DIAGNOSIS :   ckd with HFREF with DM & HTN 

TREATMENT : 
On 9/3/22
1 session of hemo dialysis 
1.fluid restrictions <1.5L/day.
2.salt restrictions <2g/day
3.TAB.LASIX 40mg BD
4.TAB.ECOSPORIN -AV OD
5.TAB.MET-XL 12.5mg OD
6.TAB.NODOSIS 500MG BD
7.TAB.SHELCAL 500MG OD
8.TAB. BIO-D3 0.25MG OD
9.TAB.OROFER-XT OD
10.inj. HAI sc Acc.to Grbs Tid
11.inj ERYTHROPOIETIN 4000U SC x ONCE WEEKLY

10/3/22 : 
S: complaints of tremors + , generalised body pains 
O : pt is c/c/c
Bp : 110/70 mm hg
HR : 84.bpm
Cvs : s1 , s 2+ 
Rs : BAE + nvbs + 
CNS : NAD 
A: ckd with HFREF with DM & HTN 
P: continued same treatment 

11/3/22 : 
S: 
Generalised body pains + 
intensity of tremors decreased compared to yesterday after dialysis . 
O : pt is c/c/c
Bp : 120/80 mmhg
HR :  84 bpm 
Cvs : s1 , s 2+ 
Rs : BAE + nvbs + 
CNS : NAD 
A : ckd with HFREF with DM & HTN 
P : continued same treatment. 
      2nd session of dialysis done. 

12/3/22 
S : fever spikes + ( 102 f) 
     generalised body pains +
O:  pt is c/c/c
Bp : 120/70 mm hg 
HR : 88 bpm
Cvs : s1 , s 2+ 
Rs : BAE + nvbs + 
CNS : NAD 
A : ckd with HFREF with DM & HTN 
P: continued same treatment. 
    Added TAB.DOLO 650mg TID i/v/o of fever spikes. 

13/2/22

S: generalised body pains + 
O : pt is C/C/C
Bp : 120/80 mm hg
Hr : 92.bpm
Cvs : s1 s2 + 
Rs : BAE +, NVBS
CNS : NAD
A : ckd with HFREF with DM & HTN 
P : Continued same treatment 
Added INJ. NEOMOL IV BD
                 INJ.PIPTAZ 2.25 gm iv/TID
      3rd session of dialysis done. 

14/3/22 
S: 
Generalised body pains increased
 fever spikes decreased. 
O : pt is drowsy 
Bp : 80/60 mmhg ( i/v/o bp 80/60 mm hg) started on nor adrenaline 6 ml/hr ) 
Hr : 96 bpm 
Cvs : s1 s2 + 
Rs : bae + , nvbs + 
Cns : 






A : ckd with HFREF with DM & HTN 
P : continued same treatment
Added inj. TRAMODOL 1amp in 100 ml NS IVX BD
Planned for LP ( i/v/o meningeal signs +)
Ophthal referral for fundoscopy ( to rule out increased ICP)

Fundoscopy was done now to rule out raised ICT. 
But due to some patient related factors (Brown cataract in right eye & hazy media + anterior chamber hypopyon in left eye) they are not able to clearly visualize optic disc to comment on raised ICT. 

Hypopyon + in left eye. 



15/3/22 : 
S :   generalised body pains +  
O : pt is drowsy & arousable 
Bp : 90/70 mm hg ( NORADRENALINE 8 ml /hr) 
Hr : 92 bpm 

Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
A : ckd with HFREF with DM & HTN 

P : Continuing same treatment

Added inj. CEFTRIAXONE 2gm i.v BD  ( I/V/O Meningitis ? ) 
Inj. THIAMINE 1amp i.v TID 

planning for MRI BRAIN  


16/3/22       ( day 8 ) 

 S :   pt is drowsy & arousable 


O : pt is drowsy & arousable 
Bp : 90/60 mm hg ( NORADRENALINE 16 ml /hr) 
Hr : 102 bpm 

Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Tone : hypertonic 
Kernig sign Positive
Brudzinski sign Positive
Reflexes Right LefUt
Biceps 2+      2+
Triceps 2+      2+
Supinator 2+      2+
Knee.      -               - 
Ankle.      -              -
Babinski No response No response 
 Lateral rectus palsy + ( false localizing sign ) 

RFT
urea 160
Creat 5.0
UA 2.2
P 5.5
Na 146
k 5.4
Cl 98

Hemogram
HB 9.2
TC 19,200
PLT 1.78
MCV 86.3

ABG ON ROOM AIR
pH 3.36
Pco2 34.9
Hco3 20.3
Pao2 95.5
Spo2 96.3

A : ckd with HFREF with DM & HTN   with ?  meningitis 
? Uremic encephalopathy 


P: CST 

 CEFTRIAXONE IS  REPLACED WITH INJ. Meropenem 500 mg IV BD

Lumbar puncture was  done




17/3/22 

 S :   pt is drowsy & arousable 


O : pt is drowsy & arousable 
Bp : 90/60 mm hg ( NORADRENALINE 20 ml /hr) 
Hr : 104 bpm 

Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Tone : hypertonia 
Kernig sign  Positive
Brudzinski sign Positive
Reflexes Right Left
Biceps  2+       2+
Triceps  2+      2+
Supinator  2+      2+
Knee.       -               - 
Ankle.      -              -
Babinski  No response No response 
 Lateral rectus palsy + ( false localizing sign ) 
A : ckd with HFREF with DM & HTN   with ?  meningitis
? Uremic encephalopathy 
? Septic emboli 

P : CST
Day 2 : meropenem 500mg i.v / BD
ADDED - INJ.DEXA 8mg /i.v/stat
INJ.VASOPRESSIN infusion (1ml/hr) i/v/o hypotension 90/60mm hg 

18/3/22 : 

 S :   pt is drowsy & arousable 


O : pt is drowsy & arousable 
Bp : 90/60 mm hg ( NORADRENALINE 20 ml /hr) 
Hr : 104 bpm 

Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Tone  : HYPERTONIA 
Kernig sign  Positive
Brudzinski sign Positive
Reflexes Right Left
Biceps  2+       2+
Triceps  2+      2+
Supinator  2+      2+
Knee.       -               - 
Ankle.      -              -
Babinski  No response No response 
 Lateral rectus palsy + ( false localizing sign ) 
A : ckd with HFREF with DM & HTN   with ?  meningitis
? Uremic encephalopathy 
? Septic emboli 


P : CST
day 3: meropenem 500 mg i.v/bd
Added INJ.VANCOMYCIN 1gm / i.v/BD i/v/o MRSA isolated in urine c/s
MRSA 




19/3/22

 S :   pt is drowsy & arousable 


O :
 pt is drowsy and arousable
Bp : 100/70 mm hg ( NORADRENALINE 2 ml /hr) 
Hr : 78 bpm 

GCS E1V1M1
Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Tone : HYPERTONIA
Kernig sign Positive
Brudzinski sign Positive
Reflexes Right Left
Biceps 2+      2+
Triceps 2+      2+
Supinator -    -
Knee.      -               - 
Ankle.      -              -

Dolls Eye -
Corneal reflex +

Babinski No response No response 

RFT
urea 259
Creat 6.3
UA 3.4
Na 148
k 6.6
Cl 101

Hemogram
HB 7.0
TC 
PLT 1.78
MCV 86.3

ABG ON ROOM AIR
pH 7.38
Pco2 30.7
Hco3 18.1
Pao2 102
Spo2 96.3

A : ckd with HFREF with DM & HTN   with ?  meningitis  ? Uremic encephalopathy 
? Septic emboli 


Plan : 
1.fluid restrictions <1.5L/day.
2.salt restrictions <2g/day
3.TAB.LASIX 40mg BD
4.TAB.ECOSPORIN -AV OD
5.TAB.MET-XL 12.5mg OD
6.TAB.NODOSIS 500MG BD
7.TAB.SHELCAL 500MG OD
8.TAB. BIO-D3 0.25MG OD
9.TAB.OROFER-XT OD
10.inj. HAI sc Acc. To Grbs Tid
11.inj ERYTHROPOIETIN 4000U SC x ONCE WEEKLY    
12.INJ. Meropenem 500 mg IV BD (day 4)
13.Inj. THIAMINE 1 AMP in 100 ml NS IV BD
14.INJ. TRAMADOL 1 AMP IN 100 ML NS IV BD
15.INJ. NEOMOL IV SOS
16.Inj.dexa 8mg IV TID
17.Inj.Vancomycin 1G IV BD(day 2 )
18. Protein powder 2tsp in 100ml milk TID
19. INJ. NORADRENALINE RATE according to MABP
20. Inj. Vasopresssin Rate according to MABP

20/3/22 : 

 S :   pt is drowsy & arousable 


O :
 pt is drowsy and arousable
Bp : 100/70 mm hg 
Hr : 78 bpm 

Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Tone : HYPERTONIC 
Kernig sign  Positive
Brudzinski sign Positive
Reflexes Right  Left
Biceps  2+       2+
Triceps  2+      2+
Supinator  -     -
Knee.       -               - 
Ankle.      -              -

Dolls Eye -
Corneal reflex +

Babinski  No response No response 

A : ckd with HFREF with DM & HTN   with ?  meningitis   ? Uremic encephalopathy 
? Septic emboli 

plan : 
CST 
Added k+binder sachets i/v/o hyperkalemia ( k+ -5.8)

20/3/22 : 

 S :   pt is drowsy & arousable 


O :
 pt is drowsy and arousable
Bp : 100/70 mm hg ( NORADRENALINE 2 ml /hr) 
Hr : 78 bpm 


Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Ton e : hypertonic 
Kernig sign  Positive
Brudzinski sign Positive
Reflexes Right  Left
Biceps  2+       2+
Triceps  2+      2+
Supinator  -     -
Knee.       -               - 
Ankle.      -              -

Dolls Eye -
Corneal reflex +

Babinski  No response No response 

A : ckd with HFREF with DM & HTN   with ?  meningitis 
plan : 
CST 

21/3/22: 
 S :   pt is drowsy & arousable 


O :
 pt is drowsy and arousable
Bp : 120 / 80 mm hg 
Hr : 82 bpm 


Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Tone  Right Left
Elbow   Hypertonic  Hypertonic
Shoulder Hypertonic Hypertonic
Hips  Hypertonic  Hypertonic
Knee  Hypertonic  Hypertonic
Kernig sign  Positive
Brudzinski sign Positive
Reflexes Right  Left
Biceps  2+       2+
Triceps  2+      2+
Supinator  -     -
Knee.       -               - 
Ankle.      -              -

Dolls Eye -
Corneal reflex +

Babinski  No response No response 

A : ckd with HFREF with DM & HTN   with ?  meningitis  ? Uremic encephalopathy 
? Septic emboli 

plan : 
CST 



 22/3/22

 S :   pt is drowsy & arousable 


O :
 pt is drowsy and arousable
Bp : 120/70 mm hg 
Hr : 92 bpm 


Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Tone : hypertonic 
Kernig sign  equivocal 
Brudzinski   : equivocal 
Reflexes Right  Left
Biceps  2+       2+
Triceps  2+      2+
Supinator  -     -
Knee.       -               - 
Ankle.      -              -

Dolls Eye -
Corneal reflex +

Babinski  No response No response 
Petechial lesions  + on plams & soles .
 
A : ckd with HFREF with DM & HTN   with ?  meningitis  ? Uremic encephalopathy 
? Septic emboli 

plan : 
CST 
Bullae + 






Aspirate from bullae 




24/3/22

Day 16
SOAP NOTES             

 S :   pt is drowsy & arousable 


O :
pt is drowsy and arousable
Bp : 100/70 mm hg
Hr : 89 bpm 


GCS : E4V3M3
Cvs : s1 s 2 +,
Rs : bae + nvbs + 
Cns : 
Tone hypertonic
Kernig sign Positive
Brudzinski sign Positive


Dolls Eye -
Corneal reflex +

Babinski No response No response 

RFT
urea 278
Creat 5.8
UA 6.1
Na 147
k 5.8
Cl 101


ABG ON ROOM AIR
pH 7.48
Pco2 24.6
Hco3 18.2
Pao2 71.9
Spo2 94

Hemogram
Hb 5.9g/dl
Tlc 23,100/cu.mm
Platelet 1.2 lakh/cu.mm

A : ckd(secondary to DM) with HFrEF with DM & HTN  
  sepsis with septic shock with bacterial meningitis  ? Uremic encephalopathy 
? Septic emboli 


Plan : 
CST 
Added  Tab. CARDARONE 100mg TID I/v/o AF 













       
 








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