65 yr old male presented with the complaints of sob and intermittent leg cramps....

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:
 65 yr old male presented with the
 complaints of intermittent calf pain since 4months,
dyspnea since last night at rest
cough since last night 
sweating since last night
palpitation   since last night 
heaviness in the chest since since last night 


Patient js a retired railway mechanic and has 7 kids (4 daughters and 3 sons).He got married to a housewife and lives in a village near by.He is an alcoholic since more than 30 years with a daily whisky intake of 90 -180 ml/day  and is a cigarette smoker (1 1/2 pack ) per day . He stopped consuming alcohol 8 years back but started again 3 months back . His last binge of alcohol was a week ago when around 180ml of whiskey was consumed. 

In 2008 , he got diagnosed with hypertension and diabetes type II on a routine check up and has been on medications since then. His son says he hasn't been complaint to his medications. 
1 year back he had right lower limb cellulitis , for which he was admitted in our hospital and the same year he had a similar episode with dyspnea ,pedal edema ,for which the patient was put on a diuretic and has been on it ever since .

Since 2 months ,the patient has been having dyspnea on exertion ,productive cough on &off and B/L pedal edema . Since last night ,he has been experiencing dyspnea at rest along with exacerbation of cough which was associated with profuse sweating and palpitations. He says he has never felt such type of heaviness in his chest before. 
pt is also complaining headache and blurring of vision since then.C/0 B/L calf pain since 1 year on and off 
H/o tingling sensation  since 4-5 years 

Pain in b/l calves is continues but 
Pain increasing on walking for around 15-20mins and subsides on taking rest 
Constricting type of pain in the calf muscles 

Patient had a history of trauma 2 years back and progressed to cellulitis of of right lower limb 

Patient denies history of heaviness or numbness in muscles and diurnal variation 


general examination:

Obese male patient 

 pallor ++
icterus -
cyanosis -
clubbing - 
lymphadenopathy-
oedema +++

vitals:
temp  98 'f
bp 190/100 mmhg 
pr 120 bpm 
rr 26 cpm 
spo2 95%
GRBS 240 mg/dl 
 O/E 
General examination from foot end 

Inspection :

No changes in 
Skin colour such as
Blackening of skin ,
Reddish blue discolouration ,
No thickened, opaque toe nails 

Palpation :

No local rise of Temperature or differences in UL AND LOWER LIMB 
Tenderness +
Pedal oedema + , non pitting type 
Peripheral pulse
 B/L 
PTA
DPA not felt 

Femoral present 

Popliteal artery Left side +
Right side -
Auscultation 
No bruit
systemic examination : 
cvs : 
Inspection
Shape of the chest normal,no scars and sinuses,no visible pulsations/apical impulse
Palpation
Apex beat present in 5th intercostal space in MCL,no parasternal heave and palpable murmurs/sounds
Auscultation
Muffled S1 S2 +,no murmurs
RS : Reduced breath sounds in B/L IAA
 Expiratory wheeze in b/l ICA ,IMA,IAA & ISA
inspiratory crepts in all the lung fields

PA: soft, not tender,bowel sounds + 
CNS: pt is conscious ,vibration in B/L LL absent and UL present
Pain,proprioception and touch intact.

Diagnosis -
1. Hypertensive Emergency With LV failure(EF-55%)
2. Known case of HTN and Type 2 DM since 12 years
3.Diabetic neuropathy
4.? peripheral vascular disease

INVESTIGATION:Day 1




Fundoscopy done
 Rt eye:senile mature catarct
lt eye:shows normal fundus

Treatment
Day 1
Strict diabetic diet
Fluid restriction less than 2l/ day
Salt restriction less than 2g/day
1.Inj.NTG5mcg/min Iv infusion
2.inj.lasix40mg/iv BD
3.T.metformin 500mg bd
4.T.metxal 25mg bd
5.Nebu.Duolin 8th hrly
Budecort 12th hrly
6.syp.ascoril 10mltid
7.tab.ecosprin 75/20 Mg hs
8.tab.clopitab 75mg Hs


6/12/20


Day 2
C/0 b/l calf muscle pain since last night
Tx
Fluid restriction less than 2l/ day
Salt restriction less than 2g/day
1.Inj.NTG 0.6 microgram to 0.4 microgram Iv infusion
2.inj.lasix40mg/iv BD
3.T.metformin 500mg bd
4.T.metxal 25mg bd
5.Nebu.Duolin 8th hrly
Budecort 12th hrly
Mucomist 8th hrly
6.syp.ascoril 10mltid
7.tab.ecosprin 75/20 Mg hs
8.tab.clopitab 75mg Hs
9.T.amlong 5mg od 
Day 3


Day 3
No fresh complaints,pedal edema decreased
Fluid restriction less than 2l/ day
Salt restriction less than 2g/day
1.Inj.NTG 1.8 ml to 1.5 ml Iv infusion and stop gradually
2.inj.lasix40mg/iv BD
3.inj.Human mixtard insulin s/c
4u-x-2u
4.T.metxal 50mg bd
5.Nebu.Duolin 8th hrly
Budecort 12th hrly
Mucomist 8th hrly
6.syp.ascoril 10ml tid
7.tab.ecosprin 150/20 Mg hs
8.tab.clopitab 75mg Hs
9.t.nicardia 30mg hs
 Day 4

1. Tab Nicardia XL 30mg /PO/OD
at 10pm
2. Tab Met XL 50mg /PO/BD
At 8am and 8pm
3. Tab Clopidogrel 75mg/PO/OD
At 8pm
4. Tab Ecosprin AV / 150/20mg /PO/HS
AT 8pm
5. Tab Lasix 40mg/PO/BD
At 8am and 4pm
6. Tab Neurobion Forte at 2pm
7. Tab Pantop 40mg/ BBF at 8am
8. Fluid restriction <1.5L/day
9.. Salt restriction <2g/day
10.Human mixtard insulin 4u-x-2u
11.syp ascoril 10ml tid

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