Short case

 

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A 62 yr old female, home maker by occupation presented to OPD with the 

 Chief complaints of

-Shortness of breath on exertion since 5 days 

-Bilateral lower limb swelling since  5 days 

-Decreased urine output which was worsening since 5 days

The above chief complaints were gradually progressive from last one year and patient had debilitating effects from last one week.

HISTORY OF PRESENTING ILLNESS : 

Patient was apparently asymptomatic 20 years back , was diagnosed to be diabetic incidentally on routine workup an an instance of fever and was started on oral hypoglycaemic agents  on TAB.GLIMI2 

1990 :

She underwent tubectomy

2002 : 

Pt developed pain abdomen for which pt was admitted in hospital and undergone HYSTERECTOMY ?FIBROIDS .

2009:

Pt developed chest pain for which he was admitted in hospital and  she was taken for primary PTCA.

On angiogram it was showing a double vessel disease (RCA+ LAD)

Since 2009  she had intermittent episodes of pain abdomen in epigastric region which was relieved on medication with PPI.

2012 

Underwent cataract surgery in two eyes with 6 months interval

2016:

She  had another episode of chest pain she was taken to hospital and was taken for primary PTCA to LAD ?stent thrombosis.

Around 2021 :

She developed bilateral pedal oedema associated with decreased urine output ,shortness of breath was diagnosed to be having a renal disease and was started on medication accordingly and continued to use OHA’s intermittently with insulin and stopped using because of poor compliance.

  

Pt had an episode of sweating, palpitations with slurring of speech and deviation of angle of mouth followed by unresponsiveness, her GRBS was 35mg/dl. MRI brain was done showing no structural lesions, and was diagnosed to be hypoglycemic seizure episode (sweating, slurred speech, deviation of mouth and unresponsiveness) and the symptoms  reverted after correction of hypoglycaemia, this episode was attributed to the change in her dosage and timing of OHA’s.

She had similar history of developing pedal oedema on and off with decreased urine output and shortness of breath 5 months back. Patient was evaluated  and was found to have anemia which was managed by systemic iron therapy. 

From the past one month patient started experiencing, nausea, vomiting, loss of appetite and dyspepsia. 

Presently admitted for similar complaints.

 

General examination:

Patient is conscious, coherent, co-operative, oriented to time, place and person.

No Icterus, Cyanosis, Lymphadenopathy,

Pallor ++

B/l pitting type  Edema +

Vitals:

Bp: 100/70mmHg 

PR: 96bpm

SpO2: 98%@RA

Temperature:98. 6°F

GRBS:  102 mg/dl

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM :

S1, S2 +, mid diastolic murmur in Tricuspid and mitral area.

Apex beat in 5th ICS on the MCL.

JVP normal.

RESPIRATORY SYSTEM :

Shape & symmetry of chest - Normal

Respiratory movements - Equal on both sides

BAE+

NVBS

Abdominal Examination

Soft, Non-tender

No organomegaly 

Bowel sounds+

CNS : 

Higher Mental Functions : intact

Cranial nerve Examination : no abnormality detected.

MOTOR SYSTEM 

                         Right.                              Left

 

Bulk                 Normal                          Normal

Tone                Right                               Left

Upper limb     Normal                           Normal

Lower limb     Normal                           Normal

 

✓Power

 UL

 Proximal             5/5                              5/5

 Distal                  5/5                              5/5

LL

Proximal             5/5                               5/5

Distal                  5/5                               5/5

✓Reflexes

Superficial reflexes

                         Right                                   Left

Plantar               -                                            -

Deep tendon reflexes

                           Right                           Left

Biceps                 2+                               2+

Triceps                2+                               1+

Supinator            1+                             Absent

Knee                    2+                               2+

Ankle                   1+                               1+

 

✓SENSORY SYSTEM

                                 Right                    Left

Pain                            +                          +

Fine touch                  +                          +

Temperature              +                          +

Vibration                   Intact                 Intact

                                   

Proprioception         Intact                 Intact            

Stereognosis           Normal              Normal

Gait - Normal

CEREBELLUM FUNCTIONS : Intact.

AUTONOMIC

No postural hypotension.

No urinary urgency, frequency, hesitancy.

No diaphoresis.

                       

       

B/L pedal edema 

INVESTIGATIONS:

Chest xray -Pa view

ECG:

USG ABDOMEN :

Diagnosis:

ANEMIA SECONDARY TO CHRONIC KIDNEY DISEASE 

? DIABETIC NEPHROPATHY 

S/P:OLD  CAD -PTCA +DES TO LAD (2009 ,2016) 

 WITH TYPE -2 DM SINCE 20 YEARS