edema, facial puffiness and sob
This is an a 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 p niatients 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.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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, investigations and come up with diagnosis and treatment plan
PATIENT CAME TO CASUALITY WITH C/O
B/L PEDAL DEMA - 20 DAYS
FACIAL PUFFINESS - 20 DAYS
BREATHLESSNESS - 1 DAY
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 10 YEARS BACK THEN WAS DIAGNOSED WITH DM-1 AND IS ON INSULIN MITARD (20U-X-16U).SHE HAD 2 EPISODES OF WEAKNESS, UNCONTROLLED SUGARS FOR WHICH SHE WAS ADMITTED FOR A DAY &DISCHARGED ( 1ST EPISODE 5YEARS BACK AND 2ND EPISODE 3 YEARS BACK RESPECTIVELY).ON NOV
2022 PATIENT WAS TAKEN TO GOVT HOSPITAL I/v/O SOB AND WAS DIAGNOSED WITH DENOVO HYPERTENSION, UNCONTROLLED SUGARS ( STARTED ON ? HTN MEDICATION).ON 2ND JAN 2023, SHE HAD EPISODES OF VOMITINGS, LOOSE STOOLS AND WAS ADMITTED IN AIIMS & WAS DIAGNOSED WITH PANCYTOPENIA ,DIABETIC NEPHROPATHY, DILATED CARDIOMYOPATHY,HTN ,VIT D DEFICIENCY RIGHT EYE PSEDUOPHAKIA AND LEFT EYE IMSC WITH HYPERPIGMENTED LESION ON RIGHT FOOT (?
CALLOSITY).6 DAYS BACK SHE DEVELOPED PEDAL EDEMA AND SOB WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE (GRADE 2 TO 4) ASSOCIATED WITH ORTHOPNOEA AND WAS BROUGHT TO OUR HOSPITAL AS HER SYMPTOMS DIDN'T SUBSIDE.
PAST HISTORY:
K/C/O DM TYPE 1 SINCE 10 YEARS AND IS ON INSULIN
K/C/O HTN FROM 2 MONTHS AND ON T TELMA+CLINIDIPINE AND T METXL
H/O OF RIGHT EYE CATARACT SURGERY: 8 YEARS BACK
PERSONAL HISTORY:
APPETITE - NORMAL
DIET - MIXED
BOWEL AND BLADDER - REGULAR
SLEEP - ADEQUATE
GENERAL EXAMINATION:
PT IS C/C/C
PALLOR: PRESENT
PEDAL EDEMA - PRESENT,PITTING TYPE, TILL KNEE NO ICTERUS,CYANOSIS,CLUBBING,
LYMPHADENOPATHY
VITALS ON ADMISSION:
PR-113 BPM
BP- 220/120MM HG
RR- 26 CPM
SPO2- 72% AT RA
GRBS - HIGH
SYSTEMIC EXAMINATION:
1) PER ABDOMEN:
INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.
PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.
ASCULTATION: BOWEL SOUNDS - HEARD
2)RESPIRATORY SYSTEM:
INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.
PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL
PERCUSSION: RESONANT BIL
ASCULTATION: BAE + , NVBS HEARD
3) CVS:
INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.
PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.
ASCULTATION: S1S2 +,NO MURMURS
4) CNS:
PATIENT WAS C/C/C.
HIGHER MENTAL FUNCTIONS- INTACT
GCS - E4V5M6
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM-NORMAL,
MOTOR SYSTEM: TONE- NORMAL, POWER- 5/5 IN ALL LIMBS REFLEXES: BICEPS - 2+, TRICEPS-2+, SUPINATOR + , KNEE - 2+, ANKLE - 2+
Diagnosis:
TYPE 1 DM WITH UNCONTROLLED SUGARS (RESOLVING)
WITH HYPERTENSIVE EMERGENCY (RESOLVED)
?NEPHROTIC SYNDROME
WITH HFpEF (EF:66%)
BICYTOPENIA SECONDARY TO B12 DEFICIENCY
ANEMIA OF CHRONIC DISEASE
HEPATIC HEMANGIOMA
HTN SINCE 2 MONTHS &DM SINCE 20 YEARS NON PROLIFERATIVE DIABETIC RETINOPATHY]
AND NECESSARY INVESTIGATIONS WERE DONE, HER SUGARS WERE FOUND TO BE HIGH AND BP BEING 220/110MMHG ON PRESENTATION AND WAS TREATED SYMPTOMATICALLY. REFRRALS WERE TAKEN FROM ENDOCRINOLOGIST I//O HIGH SUGARS,NEPHROLOGIST I/V/O HIGH CREATININE AND OPTHALMOLOGIST INIO DIABETIC &HYPERTENSIVE RETINOPATHY CHANGES.INITIALLY FOR HYPERTENSION,SHE WAS TREATED WITH T. TELMA 40MG + CLORTHALIDONE 12.5MG AND T.METXL 25MG AND LATER ON WAS FIXED ON T.NICARDIA 20MG PO/BD(8AM-X-8PM) AND ON ADVISE OF NEPHROLOGIST INJ ERYTHROPOIETIN 2000 UNITS S/C WAS GIVEN. THYRONORM 25MCG WAS STARTED I//O HYPOTHYROIDISM ON 4/2/23 AND PATIENT WAS DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION.
Patient has been in constant touch with our doctor’s via PAJR group
28/1/23:-
BLOOD PRESSURE TIMELINE:-
10 am - 220/110
11 am - 200/100
12 pm - 200/100
2 pm -190/100
3pm-180/90
5pm -170/90
6pm -170/90
7pm -170/80
8pm-160/80
9pm-150/90
10pm140/90
29/01/23:-
GRBS TIMELINE:-
12 am - 256
1 am - 249
2 am - 276
3am -323
4 am -382
5 am - 426
6 am -494
7 am-499
8am -482
9am -460
10am-540
11am- 493
12pm-480
1pm-460
2 pm -456
3pm-420
5pm -395
6pm -314
7pm -254
8pm-134
9pm-148
10pm-140
11pm-79
Here’s the conversation from today(19/2/23)
Ragi mudda na ??
With jaggery...
That's too much sugar! Please avoid Jaggery 😳
Yesterday -(24/02/23)- Friday
8am- 159/123- Tab .Nicardia 20mg
10am- 112/66
11am- 125/76
1pm-150/98- Tab .Telma 40mg
3pm-152/96
4:30pm- 154/98 .
6:15pm- 193/119 -Tab Nicardia 20mg
8pm-152/103
9:30pm- 115/65
10:20pm- 121/78
Conversation from today ( 25/2/23)
For lunch-
Took 6 Units of insulin today
25/02/23( Saturday)-
Dinner -
Yesterday - 25/02/23- Saturday
GRBS TIMELINE:-
8am- 278 ( GRBS)- 8units HAI.
Lunch- No GRBS- 6 HAI
8:30pm-GRBS-155- 6units HAI
10pm- Glargine - 8units
BLOOD PRESSURE TIMELINE:-
8am-162/126 -Tab Nicardia 20mg
10am- 126/74
11:15am -124/75
1pm- 139/92- tab Telma 40mg
3PM-146/100.
5PM-163/108- Tab Nicardia 20mg .
6:30pm -130/84
7:30pm -113/69
10pm -134/86- Tab Amlodipine 5mg.
26/02/23 ( Sunday):-
For Breakfast -
GRBS TIMELINE:-(26/02/23)
9:10am- 8HAI units - No GRBS.
1pm- 266- 12HAI.
8pm- 81 - 4 HAI.+ 8 Glargine
For Lunch-
Grbs..27/02/238:50am -HAI-8 u
1:15 pm- 279-HAI- 6 u
8:05 pm -359-HAI - 8u
10:00 pm - glargine-10 u
Anti hypertensive medication:-
8am- tab Nicardia 20mg
1pm - Tab Telma 80mg
5pm - Tab Nicardia 20mg
9pm- Tab Amlodipine 5mg .
28/02/22- Tuesday :-
GRBS-
9am- 8units HAI-
1pm- 265-10 HAI
8pm- 135-6HAI + 8 Glargine
March 1 st 2023:-
8am- 148/102- tab Nicardia 20mg
10am- 103/59
11am- 109/58
12pm- 114/68
1pm-126/82- Tab Telma 80mg
2:45- 129/81
4:15- 136/88
5:30- 149/94 -tab .Nicardia 20mg
8:10pm- 126/78
10pm- 118/72- Tab Amlong 5mg
1/03/23- GRBS
9am- FBS -322- 10HAI
1:30pm- 361-12 HAI
8pm- 63- No HAI + 8 Glargine.
Thursday: 2/03/23:-
8AM- 167/106.- Tab Nicardia 20mg
10:30AM- 105/58
12PM- 114/67
1PM- 128/80- *Tab Telma 80mg
3PM- 133/82
4:30PM- 146/95- *Tab Nicardia 20mg
6:30PM- 146/97
10PM- 111/65.- *Tab Amlong 5mg
Thursday - 2/03/23 - GRBS
8AM- Not seen-8 HAI
1PM- High -12 HAI
3PM- 226
8PM- Not seen.- 6 HAI + 8 Glargine
3/03/23- Friday
8:10am- 155/105- Nicardia 20mg
10:00 am - 105 by 53
11:00 am -107 by 63
1:00 pm - 130 by 82- Tab Telma 80mg
3pm- 126/83
4:15pm- 139/90
6:15pm- 145/94- *Tab Nicardia 20mg
8pm- 146/98
10pm- Amlodipine 10mg ?
GRBS:-
9pm- 214 - 8HAI
1:30pm- Lunch- 10HAI
8:30pm- Dinner - 226- 8 HAI+ 8 Glargine.
4/03/23- Saturday:-
8AM- 143/93- Tab Nicardia 20mg
10:30 am - 105 /59
11:30 am- 115 / 69
1pm- 130/81- Tab Telma 80mg
3PM- 141/93
4:30PM- 138/88
6PM- 149/97- Tab Nicardia 20mg
8PM- 149/101
10PM- 118/64.- Tab Amlodipine 10mg
GRBS :-
8AM- No GRBS- 6 HAI
2PM- H1- 12 HAI
8PM- 241- 8 HAI.+ 8 Glargine
5/03/23- Sunday :-
8am - No GRBS- 8 HAI.
1pm- 372- 12 HAI.
8pm- 359- 8 HAI.+ 8 Glargine.
BLOOD PRESSURE TIMELINE:-
8am- 142/92- Tab Nicardia 20mg.
10:00am -102/ 55
11:00 am- 107 /63
12:40 pm - 112/ 69 -tab Telma 80mg
3pm- 127/97.
4:40 pm- 135/ 81
6:50 pm -137 /91--Tab .Nicardia 20mg.
10:00 pm - 101/ 58 -Tab Amlodipine 10mg.
6/03/23..Monday:-
8:20am- 145/90- *Tab Nicardia 20mg
10:30am- 102 /54
11:40am- 103 /57
1pm- 110/69- *Tab Telma 80mg
3pm- 110/71
4:15pm- 124/76
6:20pm- 121/80- *Tab Nicardia 20mg
8pm- 122/74
10pm- 108/63- *Tab Amlodipine 10mg
GRBS-
8am- 541- 10HAI.
11am- 407
1pm- 261-10HAI.
4pm- 103
8pm- 262- 6 HAI + 8 Glargine.
7/03/23- Tuesday:-
8:20am- 141/91- *Tab Nicardia 20mg*
10:30 am- 95 /51
11:30 am -109/ 62
1pm- 126/73- *Tab Telma 80mg*
3:00 pm-124/ 76
4:00 pm-128 /80.
5:40 pm- 136/ 86.
6:30 pm- 148/ 93- Tablet Nicardia 20mg
10pm- 108/62- *Tab Amlodipine 10mg*
2:20am( 8/03/23)- 132/82
GRBS-
8AM- no GRBS - 8 HAI
11AM- 459
1PM- 387- 12 HAI.
3PM- 161.
8PM- 248- 6 HAI. + 8 Glargine.
2AM- 165 - ( 8/03/23).
9/03/23- Thursday:-
8AM- 129/79 . *Tab Nicardia 20mg
10:30AM - 102/ 60.
11:30 AM- 111/64
1:00 PM- 124/73.. *Tab Telma 80mg
3:30pm- 125/78
4:30 pm- 136 /80.
6:30 pm -131/84 -Tab Nicardia 20mg
8:00 pm - 130/84
10pm- 107/66- *Tab Amlodipine 10mg
GRBS:-
8AM- No GRBS- 10 HAI
1PM- 222- 10 HAI
8PM- 98- 6 HAI + 8 Glargine
10/03/23- Friday
8:15 AM- 139/91- Tab Nicardia 20mg
10:30 am- 106/ 57
11:30 am - 109 /65
1:00 pm - 114/ 70 -Tab.Telma 80mg
4:30 pm - 129 /82
6:30 pm - 139/ 86Tab Nicardia 20mg
8:00 pm - 136 /88
10:00 pm - 110/ 63Tab Amlodipine 10mg*
GRBS-
8AM- 377- 10HAI.
1PM- No GRBS- 10HAI
8PM- 155- 6HAI + 8 Glargine.
11/03/23- Saturday
9:30 am- 117 / 67 *.Tab Nicardia 20mg*
11:30 am -99 /60
1:00 pm -124 /81 . *Tab Telma 80mg*
2:30 pm- 146/86
4:00 pm -134 /83
5pm- 139/89
6:20pm- *145/92 ..Tab Nicardia 20mg
8pm- 110/63
10pm- 121/73- *Tab Amlodipine 10mg
GRBS-
8:20am- 591- 12 HAI
1pm- No GRBS- 10HAI.
8pm- 294- 8 HAI + 8 Glargine.
2AM- 434 .( On 12/03/23).
12/03/23- Sunday
8AM- 141/88.. *Tab Nicardia 20mg*
10:30 am -108 /59.
11:40 am -108 / 65.
1:00 pm -123 /75..Tab Telma 80mg.*
3:00 pm -129/80
4:20 pm - 131 /81
6:40 pm -149/ 92 ...Tab Nicardia 20mg.*
8:15 pm - 125 /77.
10:00 pm- 103/65-Tab Amlodipine 10mg.*
GRBS-
8Am- 541- 12 HAI
1:00 pm- 424...12 HAI
8PM- No GRBS- 8 HAI + 10 Glargine.
14-03-23( Tuesday)
8:00 am bp is 142 by 92...tab.nicardia 20
10:00 am bp is 110 by 57
1:00 pm...not checked..tab.telma 80..
3:40 pm bp is 118 by 75
4:30 pm bp is 130 by 82
6:15 pm bp is 136 by 89...tab.nicardia20
GRBS-
8:15 am grbs is 285...HA-12 u
12:40 pm -not checked...HA-12 u
15/03/23- Wednesday.
8am- 139/94- Tab Nicardia 20mg*
10:30 am- 96 /56
1:00 pm - 122/ 75-Tab Telma 80 mg*
4:00 pm -134/ 88
5:30 pm- 139 /89.
6:20 pm-139/92-Tab.Nicardia 20 mg*
8:00 pm- 100 /62.
10:00 pm- 121/ 74-Tab Amlodipine 10mg*
GRBS-
8am- 12HAI.
1pm- 364...12 HAI.
8pm- 181..6 HAI + 10 Glargine.
16/03/23-Thursday
8am- 141/88- Tab Nicardia 20mg.
10:30 am: 101/ 60
11:30 am: 100/ 63
1:00 pm : 125/ 74- Tab .Telma 80
3:00 pm- 127 /79
5:30 pm -145/ 97
6:15 pm- 155/ 100-Tab Nicardia 20mg
8:15 pm-117/ 67
10:15 pm- 129 /79-Tab Amlodipine 10mg.
GRBS-
8am- 464- 14 HAI
1Pm- No GRBS- 12 HAI
8pm- 320- 8HAI + 12 Glargine
17/03/23- Friday
8:00 am- 154 /101-Tab Nicardia 20mg*
10:30 am: 105 /63
11:30 am :108/ 65
1:00 pm: 123 / 80-Tab Telma 80mg
2:20 pm : 132/81
4:00 pm : 144 /95
5:40 pm : 151/ 94-Tab Nicardia 20mg
8:00 pm :132 /86
10:00 pm : 119/ 75-Tab Amlodipine 10mg*
GRBS-
8am- No GRBS - 14 HAI
2pm- 121 -8 HAI
8pm- 310- 10 HAI+ 12 Glargine
19/03/23- Sunday
8Am- High(H1).. *14 units HAI*
2pm- 446-12 HAI.
8pm- 174- 8 HAI.+ 12 Glargine.
Blood pressure:-
8:10am- 144/96.. *Tab Nicardia 20mg*
10:30 am- 106/ 62
11:30 am -110 /57
1:00 pm- 110/ 72-Tab Telma 80mg*
3:00 pm- 134 /87
4:30 pm -139/ 90
6:30 pm - 155 /94...Tab Nicardia 20mg*
7:40 pm - 131/80
10:00 pm- 115 /66-Tab Amlodipine 5mg
22/03/23- Wednesday
8:00 am-144/ 92...Tab Nicardia 20mg*
10:30 am- 110 / 64.
11:40 am -114/ 70
1pm- *Tab Telma 80mg*
3:00 pm -138 /89
4:00 pm -142 / 90
5:30 pm - 151 /101...Tab Nicardia 20mg*
7;00 pm :129/ 80
8;00 pm :121/77
10:00 pm :118 /72...Tab Amlodipine 10mg*
GRBS-
8am- no GRBS - 10HAI
12pm- Low- 6 HAI
8pm- 488- 12 HAI + 8 Glargine.
23/03/23-Thursday
8:00 am-149/ 98-Tab Nicardia 20mg*
10:30 am - 99 / 53
11:30 am- 110/ 66
1:00 pm - 121 / 74-Tab Telma 80mg*
4:15 pm - 135/ 89
5:40 pm -145/ 95.-Tab Nicardia 20mg*
7:00 pm -142/ 95
8:00 pm - 127 /81-Tab Nicardia 20mg*
10:00 pm -121/73-Tab Amlodipine 10mg*
GRBS-
8am- 310-12 HAI
2pm- No GRBS - 10 HAI
8pm - 92- 6 HAI + 6 Glargine
24/03/23- Friday
8:00 am - 137 /93.
*Tab Nicardia 20mg*
10:30 am- 99 /54
11:40 am - 111 / 64
12:40 pm - 113/ 69-Tab Telma 80mg*
2:30 pm - 129 / 81
3:30 pm -123/ 82
5:30 pm - 148/ 100. *Tab Nicardia 20mg*
8:00 pm -145 / 94
10 :00 pm-101/ 60-Tab Amlodipine 10mg
GRBS-
8am- 332- 8 HAI
2pm- No GRBS- 6 HAI
8pm- 329- 10 HAI + 8 Glargine.
27/03/23- Monday
8:00 am-134 /87-Tab Nicardia 20mg*
10: 30 am - 102 /58
11:30 am - 113 / 67.
12:40 pm - 115/ 69-Tab Telma 80 mg*
3:00 pm -128 /79.
4:30 pm - 132 /81.
5:30 pm -133 /88..Tab Nicardia 20mg
7:00 pm -136 /87
8:00 pm - 136/88
10:00 pm - 104/61...TabAmlodipine 10mg
GRBS-
8AM: 176... 8HAI
2pm: 192 ...8 HAI
8pm: 149.... 6HAI + 8 Glargine
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