50-year-old female with pedal edema, breathlessness and decreased urine output

A 50 year-old woman came to the hospital with complaints of :

- Pedal edema since 6 months. 

- Shortness of breath which aggravated since 2 months. 

- Decreased urine output since 1.5 months.

History of present illness :

The patient was apparently asymptomatic 6 months ago when she noticed swelling in both her legs which was gradually progressive, extending to her knees, a/w facial puffiness which was on and off for 6 months.

H/o increased shortness of breath since 2 months which aggravated to Grade 4 SOB since 10-15 days, a/w orthopnea, decreased sleep and appetite and nocturnal cough.

H/o decreased urine output since 1.5 months. 

H/o excessive sweating, nausea and vomiting on and off since 2 months. 

No h/o fever, cold. 

Past history :

She was diagnosed with DM, HTN 10 years ago for which she is on TAB. LINAGLIPTIN 5mg OD and TAB. CINOD 10mg OD.

No h/o TB, BA, EPILEPSY, CVD.

Personal history :

Diet- mixed, Appetite and Sleep - Decreased, Bowel movements - Regular. 

Family history :

Not significant 

General examination:

Patient consious, coherent, cooperative.

Bilateral, pitting type of pedal edema present. 

Pallor present. 

No signs of icterus, clubbing, cyanosis lymphadenopathy. 

Vitals: 

Temp: 97.3 F

Bp: 140/90 mm Hg

Pr: 87 bpm

Rr: 21 cpm

Grbs: 103 mg/dl

Spo2: 98%

Systematic examination:

CVS: S1 and S2 heard

RS: BAE +, diffuse inspiratory crepts +

P/A: soft , non tender

CNS: NAD

Clinical images :

                          Pallor - present 

                     Pedal edema - pitting 

                                      JVP 

Investigations:

Hemogram :

Hb : 8.4 gm/dl

TLC : 6,100 cells/cu mm

Platelet count : 3.34 lakh/ cu mm

PCV : 25.5%

RBC count : 2.66 million/ cu mm

2 D echo : RA, RV, LA, LV Dilated, EF 30%. 

Impression - Moderate to severe MR, Moderate TR with PAH, Mild AR. RWMA, LCX Akinetic, LAD and RCA hypohynetic, No AS/MS. Severe LV dysfunction, Sclerotix AV, Diastolic dysfunction Present.

RFT :

Urea - 80mg/dl, Creatinine - 5.8 mg/dl, Uric Acid - 7.1 mg/dl, Phosphorous - 5.3 mg/dl

Diagnosis :

Dilated cardiomyopathy EF 30%, HFrEF, Diabetic Nephropathy with Right sided Pleural Effusion with Iron deficiency anemia. 

Treatment :

1) INJ. LASIX 20mg/hr continuous infusion

2) TAB. MET XL 50 mg - PO - BD

3) TAB. ECOSPRIN 150 mg - OD

4) TAB. CLOPIDOGREL 75 mg - OD

5) TAB. ATORVAS 20mg - OD

6) Daily weight monitoring

7) SpO2/BP/PR/RR - monitoring 2nd hourly

8) Head end elevation

9) O2 supplementation SOS

10) INJ. IRON SUCROSE in 100 ml NS IV weekly twice

11) TAB. OROFER XT 100MG OD

12) INJ. HAI s/C TID 

13) TAB. METALAZONE 5mg OD

14) INJ. ERYTHROPOETIN s/c weekly twice 

15) TAB. CINOD 10mg OD

16) NEB. ASTHALIN 4 respules stat

8/12/21 and 9/12/21