A 30 YEAR OLD FEMALE WITH COMPLAINTS OF SHORTNESS OF BREATH AND PEDAL EDEMA

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINTS

Shortness of Breath since 20 days

Decreased urine output since 20 days

Pedal edema since 1 year

HISTORY OF PRESENT ILLNESS

 

Patient was apparently asymptomatic 1 year ago when she developed swelling all over the body and shortness of breath, for which she visited NIMS hospital where she was diagnosed with 

SLE with CKD with Hypothyroidism, where she was managed conservatively and the issue was resolved temporarily.

She then had complaints of 

• Bilateral pedal edema on and off since 1 year, upto knee, pitting type and no diurnal variation.
• Shortness of breath since 20 days, Grade II MMRC, aggravated on exertion and relieved on rest.
• Decreased urine output since 20 days.
• Healing ulcer over her right ankle since 20 days.

 

She also had complaints of weakness and paresthesia in both arms since 2 months 

PAST HISTORY

Not a known case of DM, HTN, Asthma, CAD, CVA, Epilepsy

FAMILY HISTORY

   No history of similar complaints in the family.

 

PERSONAL HISTORY

Appetite - Decreased

Diet - Normal

Bowel and Bladder - Regular

Sleep - Adequate

 

Daily Routine Before the onset of the illness

The patient was a daily wage laborer.

The patient used to wake up at 6 AM, perform her morning chores, tended to her children and left for work at around 10 AM.

She returned home from work by 6-7 PM, then prepared dinner, finished rest of the household chores and the went to bed by 11 PM.

 

 GENERAL EXAMINATION

The patient is conscious, coherent, cooperative

Well oriented to time place and person

VITALS

Temp - 98.5F

PR - 76 bpm

RR - 16 cpm

BP - 140/80 mmhg

GRBS - 109 mg/dl

 

Signs of Pallor present

No signs of Icterus, cyanosis, clubbing, generalised lymphadenopathy, edema.

 

SYSTEMIC EXAMINATION

CVS - S1 S2 Heard, No murmus

RS - BAE +. NVBS 

PA - Soft, Non tender, No Organomegaly

CNS - No Focal Neurological Deficits

CRANIAL NERVES - Normal

MSK EXAMINATION

TONE - Normal in Both Upper Limbs and Lower Limbs

POWER - UL - R - 3/5; L - 3/5 : LL - R - 5/5; L - 5/5

GCS - 15/15 - E4V5M6

CLINICAL

INVESTIGATIONS

 

USG - 

RIGHT KIDNEY -  GRADE I RPD CHANGES

LEFT KIDNEY - GRADE II RPD CHANGES

MILD TO MODERATE ASCITES

GRADE I FATTY LIVER

SUBCUTANEOUS EDEMA IN ANTERIOR ABDOMINAL WALL FROM UMBILLICAL REGION TO PUBIC REGION

2D ECHO

SEVERE MR, MODERATE AR, MODERATE TR WITH PAH

RWMA +, LAD AKINETIC, RCA & LCX HYPOKINETIC, NO AS/MS

SEVERE LV DYSFUNCTION

NO DIASTOLIC DYSFUNCTION

TREATMENT

 

THE PATIENT IS ON HEAMODIALYSIS

 

T PREDNISOLONE 10 MG PO OD FOR 1 WEEK

T. TORSEMIDE 100 MG PO OD

T NODOSIS 500 MG  PO BD

T NEFROSAVE PO OD

T OROFER XT PO OD

T SHELCAL LT PO OD

INJ EPO 4000 IU SC OD WEEKLY ONCE

IRON SUCROSE 200 MG IN 100 ML NS WEEKLY ONCE

T THYRONORM 12.5 MG PO OD

INJ LASIX 40 MG IV TID

INJ ZOFER 4 MG IV OD

INJ PAN 40 MG IV OD

SALT RESTRICTION <2 G/ DAY

FLUID RESTRICTION < 2 G/DAY