61 year old with Sob ,pedal oedema

 

C/o SOB since 1 month 

Pedal oedema since 15 days 

HOPI 

 PATIENT was apparently asymptomatic 1 month ago then he developed soband pedal oedema 

No h/o of burning micturition,decreased urine output 

H/o of facial puffiness present 

Patient who is a farmer by occupation stopped going to work after their family insisted he stopped the work due to his irregular sugar trends ,presented as headache ,syncopal attacks                                            

1 year back he had an ulcer to his left foot probably due to his poor foot hygiene  

For 10 days he neglected his foot ,developed maggot infestation in his foot 

Visited miriyalaguda local hospital  Aseptic dressing done for 4 days 

Then he was referred to miriyalaguda doctor ,routine investigations were done ,deranged RFT and symptoms of SOB (grade 2 to 4 ) ,orthopnea +   on MARCH 20 2021 ( Creat - 3.8 ) as of that day of admision in prvt hospital 

Amputation of left great toe was done , patient also had a history of plantar wart for which treatment was done 

AFTER 3 MONTHS OF AMPUTATION , he had local rise of temperature  ,pus discharge from the leg

By this time of infection to his leg ,his symptom of SOB which was prominent during his amputation period subsided and was bare minimum 

Then he was referred to Nalgonda govt hospital 

Unsually patient developed pain in the supra umbilical region ( 5 x 4 cm ) as of 

June 6 2021 (Creat 1.68 ) 

After necessary investigations were done he was diagnosed as obstructive epigastric  and was referred to Osmania in hyd 

Surgery was done - EEL + REDUCTION OF HERNIAL CONTENTS +1 REPAIR OF RECTUS DEFECT + LFD 

Then after  he developed SOB again  as of ( 23/10/21 ) this time along with pedal oedema and facial puffiness,no h/o decreased urine output 

As of 23 / 10/21 his Creat is  3.2 and urea 59 , on OP basis the necessary treatment was prescribed 

 On 6/12/21 he had a h/o fall from chair , he was taken to local hospital 

Diagnosed with intertrochanteric fracture,hemiarthroplasty was planned 

Took consent for surgery , A DAY Prior to surgery he had h/o blood vomitings 

After this incident he was referred to OU ,there 3 sessions of dialysis were done 

As of 11/12/21 his Creat is 5.52 

Necessary treatment was given and vomitings subsided 

In Osmania was referred to ortho where support in the form of belt was prescribed for the fracture 

Fundoscopy was also done which revealed grade 2 HYPERTENSIVE RETINOPATHY 

ON 31/12/21 went  to  private hospital for  SURGERY 

CENTRAL LINE WAS DONE AND A SESSION OF DIALYSIS BEFORE SURGERY 

HEMIARTHOPLASTY WAS DONE 

Past history 

K/c/o HTN since 20 years ,DM 3 years after onset of HTN 

Using clinidipine + nicardia ( 10 mg + 20 mg ) for HTN 

Insulin (mixtard) 10 units per day 

Personal history 

Since 5 years chronic alcoholic more than 250 ml per day 

No smoking addiction 

General examination 

BP -130/ 80 

Pulse rate -84 bpm 

Temperature -afebrile 

RR -16 cpm 

CVS - s1,s2 heard ,no murmurs 

R.S- bae + 

CNS - NAD 

P/A - soft ,non tender 

INVESTIGATIONS 

 

Provisional diagnosis  

Hypertensive nephropathy with h/o HTN since 20 years and DM since 15 years S/P amputation of great toe , obstructive epigastric hernia 

with inter trochanteric fracture 

Surgery:

 HEMIARTHROPLASTY

TREATMENT

T.LASIX 40 MG BD 

T.NODOSIS 500 MG OD 

T.SHELCAL OD 

T.PAN 40 MG OD 

T.AZITHROMYCIN X 3 DAYS 

SYP . CREMAFFIN 15 ML/PO/TID 

INJ PIPTAZ 4.5 MG IV /STAT