70 years old female with SOB

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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, and investigations, and come up with a diagnosis and treatment plan.

CASE :

Patient came to the casualty with the complaints of breathlessness since since 10 day.

 Complaints of swelling of both the legs since 10 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days back then she had fever for 1 day which is high grade, sudden onset, associated with chills and rigors, relieved by taking medication. SOB (grade-II) since 10 days which is gradually progressive and Progressed to grade-IV. No orthopnea, No PND.

C/o pedal Edema which is pitting type. 

C/o itchy scaly lesion dorsum of foot since 1 year. 

H/o Burning micturition for 3 days.

No H/o decreased urine output. 

No H/o cough, cold

No H/o chest pain, palpitations

No H/o abdominal pain, nausea, Vomiting, loose stools

PAST HISTORY:

K/C/O HTN since 4 years

Not a K/C/O DM, TB, Epilepsy, CVA, CAD

PERSONAL HISTORY:

Takes mixed diet, normal appetite

Sleep adequate 

Burning micturition since 2 days

Addictions: Drinks Whisky 90ml everyday.

Stopped 10 days back

No Significant Family History

GENERAL EXAMINATION: 

Patient is c/c/c

Mild Pallor+

No signs of icterus, cyanosis, clubbing, lymphadenopathy.

Edema of feet present 

Vitals:

Temp: 98.8F

BP: 180/100mmhg ---> 150/100mmhg

PR: 110bpm

RR: 32cpm

Spo2: 85% at RA

GRBS: 111 mg/dl

CVS: S1 S2 heard, No murmurs 

RS: BAE present, No added sounds

P/A: soft, non tender, bowel sounds heard

CNS: NFND

•Nephrologist opinion was taken on 06/04/23 i/v/o deranged RFT 

Adviced-

-Inj. Lasix 40mg IV TID

-T. Nodosis 500mg PO BD

•Dermatologist opinion was taken on 07/04/23 i/v/o itchy lesion over the feet and lower limbs since 1 year.

Diagnosed as Nummular Eczema

Adviced- 

-Liquid Paraffin L/A BD X 2 weeks

-Momate cream L/A OD X 2 weeks

-T. Teczine 5mg PO/SOS

INVESTIGATIONS:

RBS- 108mg/dl

Blood Urea- 163mg/dl

S. Creatinine - 5.6mg/dl

ECG-

USG Abdomen findings -

- Moderate B/L pleural effusion

- Raised echogenicity of B/L kidneys

- Right simple renal cortical cyst

X-Ray -

Arterial and Venous Doppler of both lower limbs:

Fever chart:

DIAGNOSIS:

CAD - NSTEMI

HFPEF (56%)

Non oliguric AKI on CKD secondary to ?Hypertensive nephropathy ?NSAIDS

Nummular eczema 

? Eczema secondary to varicose veins

B/L pleural effusion Transudative lymphocytic predominant secondary to CHF

? COPD

K/C/O HTN since 4years 

TREATMENT:

-Inj. Sodium bicarbonate 50mEq IV STAT in 100ml NS

-Inj. Lasix 40mg PO BD

-Inj. Heparin 4000IU IV QID

-Inj. Neomol 1gm IV SOS

-Tab. Ecosprin Gold 75/20/75 PO HS

-Tab. Ecosprin AV 70/20 PO HS

-Tab. Cardivas 3.125mg PO OD

-Tab.Isosorbide nitrate + Hydralazine 20mg+37.5mg PO/OD

-Tab. Hydrated Di- Hydralazine 12.5mg PO/OD

-Tab. Nicardia 20mg PO STAT

-Tab. Cinod 10mg PO OD

-IV Fluids @ 75ml/hr

-Tab. NODOSIS 500mg PO/BD

-Liquid Paraffin L/A BD

-Momate cream L/A OD

-T. Teczine 5mg PO/SOS

-T. Dolo 650mg PO/TID

-Syp. Citralka 15ml PO TID in 1 glass of water 

-Protein X Powder in 200ml of milk/water PO BD

-Nebulization with Salbutamol 6th hourly

-Strict I/O charting