44 year old male with bilateral pedal edema, shortness of breath and facial puffiness.

9th september ,2021

CHENNAMADHAVUNI DIVYA, 9th semester

Roll number-21

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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 diagnosis and treatment plan.

Following is the view of my case :

Date of admission :21-8-2021

Chief complaints :

A 44 year old male patient has come to the opd with the chief complaints of ,

Bilateral pedal edema since 5 months.
shortness of breath since one months.
facial puffiness since one month.

History of present illness :

Patient was apparently asymptomatic 5 months back and then he developed ,

Bilateral pedal edema since 5 months.

facial puffiness since one month .

He developed shortness of breath GRADE = 3 to GRADE =4 of( NYHA classification) which was, insidious in onset (ever since he was put on dialysis according to him) and gradually progressing in nature.

He had Fever yesterday ,which was insidious in onset ,high grade ,on and off in nature and associated with chills and dry cough.

He has pain on the right side of the chest,

Onset - sudden

Duration -since 4-5 days.

Type - pricking

Aggrevated on sleeping on the side effected, touching the site of pain .

Relieved on sitting position ,not associated with swelling and tenderness.

He had no complaints of: Loss of smell, vomitings , nausea ,chest pain, no decreased urine output.

History of past illness :

Patient underwent 5 sessions of hemodialysis on CRF past month and is not on hemodialysis since 8 days.

known case of hypertension since 4-5 years and he is on anti hypertensives, does not take his medications regularly.

Diagnosed with CkD ,1 and half year back and was on medications for 6 months which were stopped later with no valid reason.

He was diagnosed with COVID-19 5 months back ,was on home isolation and tested positive in a week, developed bilateral pedal edema since then.

Not a known case of Diabetes ,asthma ,tuberculosis ,epilepsy ,CVA

Has a history of blood transfusion.

No significant surgical history

No known allergic history

Personal history :

Diet - mixed

Appetite - decreased

sleep - adequate

Bowel and Bladder movements - regular

Addictions - drinks alcohol on a regular basis, decreased since 2 years.

chews tobacco on a regular basis, decreased since 2 years.

Drug history :

Nimodipine 10 -20 mg since 1 and half year.

Family history :

No significant family history

General examination :

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

at the time of examination

He is examined in a well lit room, with consent taken.

He is moderately built and well nourished.

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

lymphadenopathy - absent

Pedal edema - present

Vitals : on the day of admission (21/8/2021)

Temperature - 102degrees F

Pulse rate - 105 bpm

Respiratory rate - 40 cpm

Blood pressure - 170/100 mmHg

SpO2 - 85-88% on Room air

Patient was shifted to hemodialysis in the morning( 10:00AM) with UF = 2 liters target.

Patient's SBP shooted to 230/130 mmHg half n hour after starting the dialysis and he was in Acute cardiogenic pulmonary edema and distress of diaphoresis.

He was tachyapneic with RR- 60cpm

SPo2: 75-78 on room air and was connected to high flow O2 (10-12 lit).

Hemodialysis subtypes has been changed to isolate 1.5 lit.

Nebulization with spravent and budecort -STAT

Inj. Nitroglycerine 5ml =5mg ,3ml IV bolus given over 2 minutes

Inj. carix 80mg / IV / STAT.

Inj. Avil 2u / IV / STAT.

Inj. Hydrocortisone 100mg /IV / STAT.

Inj. Neomal 1g / IV / STAT.

Inj. Nitroglycerine one more dose 2ml IV Bolus was given - patient was still tachyapneic with RR: 40 cpm, on high flow O2 (10-12 lit)- SP02 : 90-92 % and 84-88 % on room air.

Inj. Nitroglycerine (2 amp in 40ml 5% D) started with 3ml/hour ,50 micrograms /min -dose ,increased and decreased according to the SBP levels.

Inj. Labetalol 20mg / IV Bolus given over 5 min,

BP : 200/100 mmHg

PR : 172 bpm

After which patient was started on NIV Bipap with in V/O falling sats

SPo2 : 95-98%

Respiratory system ; crackles decreased bilaterally only in basal areas.

Tab. Nifedipine 20 mg / Po / STAT

Tab. Arlcamine 0.1mg / Po / STAT

Hemodialysis was continued for 2 hours.

Patient was shifted back to ICU at 2:00 Am

He was connected back to NIV overnight .