A 65 year old with orthopnea

 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 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

 A 65 year old male farmer by occupation came to medicine OPD with chief complaints of shortness of breath and pedal edema since 15 days 

HOPI-

Patient was apparently asymptomatic 6 years back then he developed high grade fever associated with chills rigor and cough

Then he was diagnosed with hypertension and diabetes mellitus


No history of nausea ,vomitings and get treated by local RMP by injections ( injections unknown) (oral medication does not relieve the fever) .this type of fever used to reappear every 6-7 months ( not seasonal) and associated with similar symptoms .

Then 3 months 15 days back then he developed shortness of breath which is insidious in onset which increased on supine position. (orthopnea) after that they went to local hospital where he was referred to a higher centre where they have done coronary angiogram which showed proximal LAD 50 % ; OM 3 70 % stenosis and renal angiogram which showed BILATERAL RENAL ARTERY stenosis ( left 90% and right 50% )



:-Then PTCA was done to patient on 12/11/21 to OM 3 and PTRA to left renal artery.

Then Shortness of Breath was resolved.

After 2 months i.e., 15 days back he again developed shortness of breath ( orthopnea) and pedal edema which is pitting type and went to hospital on 2/2/22 and regular cbp was done which showed HB of 6 and 2 blood transfusions are done and the HB improved to 7.9 (5/2/22)


On 14/2/22 he presented to our hospital where they increased the dose of previous tablet and done investigations as follows:-


After 2 months i.e., 15 days back he again developed shortness of breath ( orthopnea) and pedal edema which is pitting type and went to hospital on 2/2/22 and regular cbp was done which showed HB of 6 and 2 blood transfusions are done and the HB improved to 7.9 (5/2/22)


On 14/2/22 he presented to our hospital where they increased the dose of previous tablet and done investigations as follows





On 16/2 and 17/2 night the SOB(orthopnea) of the patient increased and came to our hospital where the condition of the patient deteriorated and was admitted in th ICU . 

Past history
Diabetic and hypertensive since 6 years 
No thyroid TB leprosy


Allergic history
No allergies to any kind of medications


Drug history
Oral diabetic drugs

PERSONAL HISTORY:-
Diet :- normal
Appetite:- normal
B&B :- normal
Addictions :- smoking 

GENERAL EXAMINATION:-
Patient is on mechanical ventilator. Unconscious. 
Patient is unconscious
Pedal edema positive(pitting)
No icterus ,no cyanosis, no clubbing no lymphadenopathy


Vitals:- 
Temp:- afebrile

PR - 100 bpm

BP - 150 / 90 mm hg

SpO 2 g 70 %

GRBS - 126 gm%

 

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