60 yr old female with CAD with heart failure with reduced ejection fraction

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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. 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 patients 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.

Patient presented to casualty with chief complaints of pedal edema since 5 days and shortness of breath since 3 days (approx. 3rd dec)

Patient was apparently asymptomatic 1 month back the she developed vomitings insidious in onset, daily 4 to 5 times watery in consistency, non projectile, non bilious, non blood stained, this continued for 4 to 5 days no known aggravating factors relieved on medication

Then the patient developed fever insidious in onset, continuous, low grade associated with chills and rigors with no associated aggravating and relieving factors.

The patient also developed blackish discolouration of the 3rd toe of left foot, (approx. 6th dec) the patient observed it 2 to 3 days after the symptoms started for which the patient was patient was taken to NIMS (approx. 8th dec) for all the above conditions where they treated the fever, chills, rigors and vomitings conservatively and were advised on removal of the third great toe for which the patient got admitted in our hospital on 13th December for the procedure and underwent disarticulation and debridement of 3rd toe of left foot. Later she was admitted in the hospital for 9 days and discharged on 21st December

Later the patient presented to casualty on 25th December with complaints of pedal edema for both legs since 5 days and shortness of breath since 3 days

Pedal edema was gradually progressive, not relieving, pitting type.

The patient had complaints of SOB which gradually progressed to MMRC grade 4 while presented to casualty, aggravated on sleeping position and relieved on sitting position.

The patient also had an ulcer of size 16x4x1 cm present over the plantar aspect of the left foot extending from the base of 3rd metatarsal to dorsum of the left foot

No H/o seasonal variations or episodes

No h/o giddiness or diarrhea

No h/o seizure episodes

PAST HISTORY

History of diabetes since 12 years using metformin 500mg and glimiperide Per oral once in the morning

Not a known case of hypertension, epilepsy, CAD, CVA, thyroid disorders, epilepsy

H/o disarticulation and debridement of 3rd toe of left foot 20 days back

PERSONAL HISTORY

Apetite decreased

Bowel and bladder movements normal

Mixed diet

Drinks toddy occasionally once a month

FAMILY HISTORY

No known cases of diabetes in family

GENERAL EXAMINATION

Patient is conscious, coherent, and cooperative

Moderately built

No pallor, icterus, lymphadenopathy, clubbing, cyanosis

VITALS

PR: - 140 beats per minute

Temperature: - 98 F

Respiration: - 32cpm

Blood pressure: - 90/70 mmHg

GRBS: - 419mg/dl

PROGRESSION

On the night of 25th the patient developed tachycardia upon ecg it was identified as ventricular tachycardia to which she was administered amiodarone and she was bought to normal sinus rhythm. Later on the patient developed bradycardia and her stats started to drop suddenly for which CPR was done and she was intubated and kept on a mechanical ventilator for 10 days from 25th of December to 2nd January. 

She was shifted from mechanical ventilator to oxygen through t piece on 2nd and extubated on 3rd January 

During CPR she suffered from a fracture of 2nd rib on the right side.

She developed bed sores in the sacral region on 31st December initially of grade 1 which now progressed to grade 2 bed sores

Prior to getting admitted here she was diagnosed to having a fungal ball in the left upper left lobe which is thought to be aspergilloma

DIAGNOSIS

Diabetic ketoacidosis

Acute pulmonary edema secondary to acute coronary syndrome

Herat failure with reduced ejection fraction

Severe LV dysfunction

Left upper lobe fungal ball (aspergilloma)