65 year man with Dyspnea on exertion and bilateral lower limb edema
A 65 year old from ********* presented with the complaints of
Bilateral lower limb swelling since 1 month
Dyspnea on exertion since 20 days
Black coloured stools since 20 days
A 65 year old man, previously used to work as a farmer 6 years back, got married to his far relative and has been happily married with 3 children.
He has been an occasional alcoholic and a beedi smoker and smokes around 3 to 4 beedis per day. He smoked last 3 months back.
25 years back, his left index finger was amputated after it got hit by a tractor.
20 years back he got into a fight with his friends following which he had a trauma to his head following which he had one episode of seizure and he was put on antiepileptics, which he used for 3 years and stopped.
Since 6 years - He has been experiencing bilateral knee joint pains so much that he stopped working. He paid a visit to our hospital and was advised for a total knee replacement. However, on further investigating him he was told that he had a heart condition because of which he cannot be operated.
He first developed pain in his right knee following which he developed left knee pain. Over the past 1 month he has even developed pain in his bilateral wrist joint, following which he developed pain in his bilateral elbow joint and shoulder joints.
2 years back - He paid a visit to a hospital for difficulty in seeing far objects for which he was prescribed spectacles, then he got even diagnosed to be a diabetic and has been on irregular medications since then
Since 1 month - He developed bilateral lower limb swelling, first he says he developed upto his ankles which gradually progressed to his thighs over a month.
Since 20 days he also has been experiencing dyspnea on walking for short distances and he also started noticed jet black coloured stools.
He also says he has to wake up from his sleep 4 times everyday to pass urine. He says he passes urine frequently but in small quantity.
Patient is a thin built man
Pallor +
Bilateral pitting type of pedal edema extending upto thighs +
PR - 110bpm
BP - 90/60mmhg
RR - 18 cpm
Spo2 - 99%
GRBS - 150mg/dl
JVP raised
Systemic Examination:
On Inspection :
Apical impulse visible
Showing bilateral lower limb pitting edema extending upto thighs
Transverse - 23 cm
AP diameter - 19 cm
Inspection:
Palpation:
Palpable apex beat
Apex beat palpated in 6th ICS 1 cm lateral to the Midclavicular line
No palpale pulsations in aortic and Pulmonary areas
No palpable pulsations in sternoclavicular area
No left parasternal pulsations
No epigastric pulsations palpable
Auscultation:
S1,S2 +
Respiratory system -
Bilateral airway entry +
Clear
Per Abdomen-
Non tender
Bowel sounds +
Provisional diagnosis:
1.Anemia under evaluation
2.Heart failure with preserved ejection fraction
3. Polyarthralgia under evaluation
4. Known case of Diabetes mellitus since 2 years
Hb - 2.7
TLC - 4500
Platelets - 3.20 L/cumm
MCV - 56.7
Retic count - 0.9%
Peripheral smear showing Anisopoikilocytosis, microcytic hypochromic picture with pencil forms, tear drop cells and few macrocytes
Serum Ferritin - 3.6
Serum creatinine - 1
Blood urea - 23
Treatment:
1. Inj Lasix 40mg/IV/BD
At 8am and 4pm
2. Inj Iron Sucrose 1amp in 100ml NS/IV/OD
3. Tab Orofer XT/PO/BD
4. Fluid Restriction < 1 litre/day
Salt Restriction <2grams/day
Plan for tomorrow:
1. Upper GI endoscopy tomorrow to find out the cause for his melena
2. Orthopedics opinion for bilateral knee joint pain
Day 1:
His Dyspnea reduced
He had no fever spikes
PR - 78 bpm
Bp - 110/70mmhg
Temp - 98.4 F
JVP raised
Cvs -
Apex beat in 6th ICS, 1cm lateral to MCL
S1,s2+
Lungs-
Bilateral ISA crepts +
Per Abdomen
Non tender
Bowel sounds +
A -
His Hb was 2.7 g/dl
TLC - 4500 cells/cumm
Platelets - 2.55 L/cumm
Anemia due to Iron deficiency and Vit b12 deficiency
And upper GI blood loss
Heart failure with preserved EF of 58%
Known Diabetic since 2 years
P-
Gastroenterologist opinion was taken for upper GI endoscopy but PRBC transfusion was advised
1 PRBC transfusion was given
Treatment plan:
Salt restriction <2gm/day
Fluid restriction<1.5 l/day
Inj.optineuroin 1 ampoule in100ml NS/IV/OD
Inj.Iron sucrose 1 ampoule IV /OD
Tab.orofer XT PO/BD
Tab Metformin 500mg/PO/OD
Inj.pan 40 mg IV/OD
Day 2:
65 year old man with Iron Deficiency Anemia
HFPEF
With a history of Upper GI bleed since 1 month
S - no fever spikes, sob subsided
O -
PR - 80 bpm
BP - 80/40mmhg
Afebrile
Spo2 - at 99% on RA
RR - 20 cpm
JVP raised
Per Abdomen-
Distended
No tenderness
Bowel sounds +
Lungs -
BAE+ ,clear
Cvs -
Apical impulse visible
Apex beat present in 6th ICS 1 cm lateral to MCL
s1,s2 +
A -
We repeated his chest xray to see if it was a phantom tumor which responded to our diuretics
His repeat Chest Xray PA view
His chest xray PA shows straightening of the left heart border and batwing appearance
? Leucocytosis post blood transfusion
HFpEF with EF-58%
Hypoproliferative anemia secondary to iron deficiency
Known case of Diabetic since 2 years
P-
Salt restriction <2gm/day
Fluid restriction<1.5 l/day
Inj.optineuroin 1 ampoule in100ml NS/IV/OD
Inj.Iron sucrose 1 ampoule IV /OD
Tab.orofer XT PO/BD
Tab Metformin 500mg/PO/OD
Inj.pan 40 mg IV/OD
Syrup.Cremaffine plus 15 ml PO/TID
Strict I/O Charting
Temp Charting 4th hourly
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