Case 10.45 F with breathlessness,pulmonary edema,heart failure

DOA 21/10/2024

DOD 25/10/2024

Diagnosis

1.ACUTE PULMONARY PEDEMA SECONDARY TO CKD WITH DIABETIC NEPHROPATHY

2.HEART FAILURE WITH PRESERVED EJECTION FRACTION(EF56%)

3.WITH ANEMIA OF CHRONIC DISEASE

4.K/C/O DM2 SINCE 15 YRS

5.K/C/O HTN SINCE 10 YRS

6.K/C/O HYPOTHYROIDISM SINCE 1YR

Case History and Clinical Findings

PT WAS BROUGHT TO THE CASUALTY WITH C/O BREATHLESSNESS SINCE 2 DAYS

HOPI: PT WAS APPARANTLY NORMAL 2DAYS BACK THEN SHE DEVELOPED

BREATHLESSSNESS GRADE2 MMRC INITIALLY AND GRADUALLY PROGRESSED TO GRADE

4

ASSOCIATED WITH COUGH WITH EXPECTORATION-GREENISH MUCOID SPUTUM SINCE 4

DAYS

FEVER SINCE 4 DAYS-HIGH GRADE,INTERMITTENT,ASSOCIATED WITH CHILLS AND RIGORS

AND RELIEVED BY MEDICATION

C/O B/L SWELLING OF LOWER LIMBS-PITTING TYPE,EXTENDED UPTO THE KNEE SINCE

1YR(ON AND OFF)

C/O DECREASED URINE OUTPUT SINCE 1YR-VERY MUCH REDUCED SINCE 3 DAYS

C/O ABDOMINAL DISTENSION SINCE 4-5 MONTHS,ORTHOPNEA PRESENT

NO C/O CHEST PAIN,PALPITATIONS,PND,SWEATING ,GIDDINESS

PAST HISTORY-K/C/O DM2(SINCE 15 YRS) INITIALLY STARTED INSULIN BUT NOW ON OHAS-

SITAGLIPTIN 50+METFORMIN1000+GLIMIPERIDE2

K/C/O HTN SINCE 10 YRS USING T.PRAZOSIN 5MG

K/C/O HYPOTHYROIDISM SINCE 1 YR USING T.THYRONORM 150MCG

K/C/O CKD SINCE 1YR ON CONSERVATIVE MANAGEMENT

NOT K/C/O CVA,CAD,TB,EPILEPSY,ASTHMA

GENERAL EXAMINATION-PT IS C/C/C

PALLOR,EDEMA PRESENT(PITTING TYPE),NO ICTERUS CYANOSIS LYMPHADENOPATHY

BP-240/100MMHG

PR112BPM

RR42CPM

SPO2 67% AT RA

GRBS 100MG%

SYSTEMIC EXAMINATION

CVS: INSPECTION-JVP NOT RAISED,CHEST WALL SHAPE NORMAL AND SYMMETRICAL,NO

DILATED VEINS/SCARS,KYPHOSCOLIOSIS ABSENT

PALPATION-APICAL IMPULSE NORMAL NO PARASTERNAL HEAVE,NO THRILLS

PERCUSSION-DULL NOTE PRESENT

AUSCULTATION-S1S2 PRESENT,NO MURMURS

RESPIRATORY SYSTEM: BAE PRESENT , NVBS,DIFFUSE CREBS PRESENT

P/A: SOFT,NON TENDER,NO ORGANOMEGALY

CNS: NO FOCAL NEUROLOGICAL DEFICITS

Investigation

ABG

PH 7.38PCO2 32.2PO2 158HCO3 19.0St.HCO3 20.3BEB -5.0BEecf -5.1TCO2 41.3O2 Sat 99.3O2

Count 9.5

BLOOD UREA 70 mg/dl 42-12 mg/dl

SERUM CREATININE 1.9 mg/dl 1.1-0.6 mg/dl

SERUM ELECTROLYTES (Na, K, C l) SODIUM 130 mmol/L 145-136 mmol/LPOTASSIUM 3.7

mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) Total Bilurubin 0.60 mg/dl Direct Bilurubin 0.19 mg/dl SGOT(AST) 29

IU/L SGPT(ALT) 20 IU/L ALKALINE PHOSPHATASE 110 IU/L TOTAL PROTEINS 5.8 gm/dl

ALBUMIN 3.0 gm/dl A/G RATIO 1.06

HBsAg-RAPID NegativeAnti HCV Antibodies - RAPID Non Reactive

COMPLETE URINE EXAMINATION (CUE) COLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS

4-6EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS NilSERUM ELECTROLYTES (Na, K, C l) SODIUM 132

mmol/LPOTASSIUM 3.5 mmol/L CHLORIDE 102 mmol/L

T3, T4, TSH T3 0.36 ng/ml T4 15.17 micro g/dl TSH 5.4 micro Iu/ml

SERUM CREATININE 2.0 mg/dl SERUM ELECTROLYTES (Na, K, C l) SODIUM 134 mmol/L

POTASSIUM 3.3 mmol/L CHLORIDE 103 mmol/L

FBS 90 mg/dl

PLBS 159 mg/dl

Hba1c 6%

BLOOD UREA 88 mg/dl SERUM CREATININE 1.5 mg/dl

SERUM ELECTROLYTES (Na, K, C l) SODIUM 135 mmol/LPOTASSIUM 3.6 mmol/L CHLORIDE 98

mmol/L

Treatment Given(Enter only Generic Name)

1.INTERMITTENT C-PAPFLUID

2.RESTRICTION LESS THAN 1LIT/DAY

3.SALT RESTRICTION LESS THAN 2-3GMS/DAY

4.INJ NTG 1CC IN 4ML NS ICC IV STAT

5.INJ.LASIX 40MG IV BD

6.INJ.HAI S/C TID ACCORDING TO GRBS

7.T.PRAZOSIN 5MG PO/OD

8.T.THYROXIN 150MCG PO/OD BEFORE BREAKFAST

9.NODOSIS 500MG PO/OD

10.T.OLKEN TRIO PO/OD

11.INJ.AUGMENTIN 1.2GM IV TID

12.SYP ASCORYL LS 10ML PO/TID

13.T.VYMADA 50MG PO/BD

14.T.VYSOV-D 100/10 PO/OD

Advice at Discharge

1.FLUID RESTRICTION LESS THAN 1LIT/DAY

2.SALT RESTRICTION LESS THAN 2-3GMS/DAY

3.INJ HAI S/C 6 UNITS BD 8 AM ,8 PM BEFORE FOOD

4.TAB..AUGMENTIN 625 MG PO/BD X 3DAYS

5.TAB LASIX 40 MG BD X 15 DAYS

6.TAB VYSOV D 100/ 10 PO /OD X 15 DAYS (1PM)

7.TAB VYMADA 50 MG PO OD X 15 DAYS

8.TAB PRAZOSIN 5MG PO OD X 15 DAYS

9.TAB OLKEM TRIO PO OD X 15 DAYS

10.TAB NODOSIS 500MG PO BD X 15 DAYS

11.TAB THYRONORM 150 MCG PO OD TO BE CONTINUED

12.SYP ASCORIL LS 10 ML PO BD X 5DAYS

13.TAB PAN 40 MG PO OD

14.T.SHELCAL XT PO/OD 2PM FOR 15 DAYS

15.MONITOR GLUCOSE AT HOME BY GLUCOMETER AT 7AM,10AM,4PM,10PM

Follow up in february 2025

FBS 104 mg/dl

PLBS 140 mg/dl

Hba1C 5.9 %