Case 2.75 M with SOB 3 hrs Dm2CKD

Diagnosis

HFPEF (EF53%) WITH PULMONARY EDEMA(RESOLVED)

RENAL AKI ON CKD(RESOLVING)

COMMUNITY AQUIRED PNEMONIA

K/C/O DMT2 AND HTN

POST EXTUBATION DAY 5

Case History and Clinical Findings

PT BROUGHT TO CASULTUY WITH H/O ET TUBE INSITU ON T,PIECE FROM OUT SIDE

HOSPITAL 8PM

PT HAD H/O FEVER 3 DAYS BACK COUGH AND SOB 3DAYS BACK

ON SATURDAY PT ATTENDER TOOK HIM TO PVT. HOSPITAL AT HYD

PT WAS UN RESPONSIVE AND INTUBATED THERE ON MON MORNING PT CAME

CINSIOUSNESS SINCE THEN VENTILATOR SUPPORT REMOVED AND PT KEPT ON T.PIECE

PAST HISTORY:

K/C/O HTN SINCE 2YRS

K/C/O DM SINCE 2 YRS ON T.METFORMIN 500 OD

NK/C/O TB,ASTHMA, EPILEPSY,THYROID DISORDER

GENERAL EXAMINATION :

PATIENT IS C/C/C

NO SIGNS OF PALLOR,ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, PEDAL

EDEMA

BP: 130/100 MMHG

PR: 100 BPM

RR: 18 CPM

SPO2: 98%

GRBS 124MG/DL

SYSTEMIC EXAMINATION :

CVS: S1S2 +, NO MURMURS

RS: BLAE + NVBS HEARD, NO ADDED SOUNDS

P/A: SOFT NON TENDER, NO ORGANOMEGALY

BOWEL SOUNDS PRESENT

CNS: NO FND

COURSE IN HOSPITAL:

PT PRESENTED TO CASULTUY WITH H/O ET TUBE INSITU ON T,PIECE (POST INTUBATION

DAY3) PRESENTING VITALS BP 170/100

PR 100BPM

RR 18CPM

SPO2 92%ON 4 LIT OF O2

GCS E4VTM6 AND PT WAS INTUBATED OUTSIDE THE HSPTL I/V/O LOW GCS WITH

PULMONARY EDEMA SECONDARY TO HF

PT WAS FURTHER INVESTIGATED WITH ABG SHOWING METABOLIC ACIDOSIS AND

EXTUBATED ON 2/12/2024 ON PROGRESSION PT WAS STATED ON IV ANTIBIOTICS I/V/O

DERANGED RFT NEPRO OPINION WAS TAKEN AND ADVISED HEMODIALYSIS BUT PT

ATTENDERS WERE NOT READY AND WANT CONSERVATIVE MANAGEMENT PT IS

DISCHARGED IN HEMODINAMICALLY STABLE CONDITION

Investigation

RFT 02-12-2024 09:10:PMUREA 139 mg/dl 50-17 mg/dlCREATININE 5.5 mg/dl 1.3-0.8 mg/dlURIC

ACID 6.6 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.8 mg/dl 4.5-

FBS-134 mg/dl

PLBS- 216 mg/dl

Hba1C -6.3

2.5 mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 4.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 02-12-2024 09:10:PMTotal Bilurubin 0.97 mg/dl 1-0 mg/dlDirect

Bilurubin 0.19 mg/dl 0.2-0.0 mg/dlSGOT(AST) 44 IU/L 35-0 IU/LSGPT(ALT) 40 IU/L 45-0

IU/LALKALINE PHOSPHATASE 148 IU/L 119-56 IU/LTOTAL PROTEINS 5.7 gm/dl 8.3-6.4

gm/dlALBUMIN 3.0 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.18COMPLETE URINE EXAMINATION (CUE)

02-12-2024 09:10:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY

1.010ALBUMIN ++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL

CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS

AbsentOTHERS Nil

HBsAg-RAPID 02-12-2024 09:10:PM NegativeAnti HCV Antibodies - RAPID 02-12-2024 09:10:PM

Non Reactive

POST LUNCH BLOOD SUGAR 02-12-2024 09:13:PM 119 mg/dl 140-0 mg/dlABG 02-12-2024

09:28:PMPH 7.32PCO2 31.5PO2 74.9HCO3 16.1St.HCO3 17.5BEB -8.5BEecf -8.7TCO2 34.3O2 Sat

93.8O2 Count 12.3

ABG 02-12-2024 11:20:PMPH 7.32PCO2 24.9PO2 50.0HCO3 12.7St.HCO3 14.6BEB -12.0BEecf -

12.2TCO2 28.0O2 Sat 80.8O2 Count 7.2ABG 02-12-2024 11:21:PMPH 7.34PCO2 28.2PO2

65.5HCO3 15.0St.HCO3 17.0BEB -9.1BEecf -9.6TCO2 31.2O2 Sat 90.9O2 Count 14.1

ABG 03-12-2024 05:25:PMPH 7.37PCO2 35.0PO2 87.8HCO3 19.8St.HCO3 20.8BEB -4.4BEecf -

4.6TCO2 40.4O2 Sat 95.7O2 Count 15.8RFT 03-12-2024 11:26:PMUREA 188 mg/dl 50-17

mg/dlCREATININE 5.9 mg/dl 1.3-0.8 mg/dlURIC ACID 7.9 mmol/L 7.2-3.5 mmol/LCALCIUM 9.8

mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.5 mg/dl 4.5-2.5 mg/dlSODIUM 135 mmol/L 145-136

mmol/LPOTASSIUM 4.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99 mmol/L 98-107 mmol/L

RFT 04-12-2024 11:38:PMUREA 174 mg/dl 50-17 mg/dlCREATININE 5.6 mg/dl 1.3-0.8 mg/dlURIC

ACID 8.1 mmol/L 7.2-3.5 mmol/LCALCIUM 9.2 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 5.4 mg/dl 4.5-

2.5 mg/dlSODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

99 mmol/L 98-107 mmol/LABG 04-12-2024 11:38:PMPH 7.43PCO2 24.7PO2 116HCO3

16.1St.HCO3 18.7BEB -7.0BEecf -7.4TCO2 34.4O2 Sat 96.4O2 Count 10.6

RFT 05-12-2024 11:13:PMUREA 165 mg/dl 50-17 mg/dlCREATININE 4.9 mg/dl 1.3-0.8 mg/dlURIC

ACID 7.6 mmol/L 7.2-3.5 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.8 mg/dl 4.5-

2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 4.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

99 mmol/L 98-107 mmol/LRFT 06-12-2024 04:03:PMUREA 145 mg/dl 50-17 mg/dlCREATININE 4.6

mg/dl 1.3-0.8 mg/dlURIC ACID 7.2 mmol/L 7.2-3.5 mmol/LCALCIUM 9.4 mg/dl 10.2-8.6

mg/dlPHOSPHOROUS 4.2 mg/dl 4.5-2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM

3.7 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 101 mmol/L 98-107 mmol/L

RFT 7/12/24

UREA 145

CREATINE 4.6

CA 7.2

NA 135

K 3.7

CL 101

HB 2/12/24

HB 9.4

PCV 28.0

TLC 12,400

RBC 3.36

PLT 1.5

HB ON 4/12/2024

HB 10.1

PCV 29.5

TLC 9,800

RBC 3.56

PLT 1.78

HB ON 5/12/2024

HB 9.2

PCV 26.9

TLC 7,100

PLT1.65

RBC 3.26

6/12/2024

HB 8.6

PCV 26.0

TLC 7,800

RBC 3.07

PLT 1.50

HB ON 7/12/2024

HB8.8

PCV 26.9

TLC 10,000

RBC 3.18

PLT 1.53

REFERAL TO NEPHO ON 3/12/24 I/V/O UREA 139 CREAT 5.5

ADV FLUID RESTRCTION <2G/DAY

SALT RESTRICTION <2G / DAY

INJ LASIX 20MG IV/BD

TAB SHELCAL XT PO/OD

TAB NODOSIS 500MG PO/OD

TAB OROFER XT PO/OD

STRICT I/O CHARTING

USG ABDOMEN ON 2/12/2024 I/V/O RPD CHANGES

IMPRESSION

GRADE 1 TO 2 RPD CHANGES IN B/L KIDNEYS

LEFT RENAL CORTICAL CYST OF SIZE 12X10MM

Treatment Given(Enter only Generic Name)

HEAD END ELEVATION

CONTINUE BIPAP SUPPORT

SALT RESTRICTION <2G / DAY

IVF 50ML/HR

RT FEEDS 200ML MILK EVERY 47THRLY AND 100 ML WATER EVERY 2 HRLY

INJ MEROPENUM 500MG IV/BD

INJ LASIX 20MG IV/BD

INJ PAN 40MG IV/BD

INJ HAI SC/TID (ACC TO GRBS INFORM)

TAB CINOD 10MG RT/BD

TAB NODOSIS 500MG RT/BD

TAB SHELCAL XT RT/BD

TAB ROSVAS CV 20MG RT/HS

TAB PULMOCLEAR RT/OD

NEB WITH BUDECORT 12TH HRLY

IPRAVENT 6TH HRLY

MUCOMIST 6TH HRLY

CAP FLUVIR 75 MG RT/BD

GRBS 7 HRLY PROFILE

Advice at Discharge

SALT RESTRICTION <2G / DAY

FLUID RESTRICTION <1.5LITER/DAY

TAB LASIX 20MG PO/BD

TAB GLIMI M1 PO/BD

TAB CINOD 10MG PO/BD

TAB NODOSIS 500MG PO/BD

TAB SHELCAL XT PO/BD

TAB ROSVAS CV 20MG PO/HS

TAB PULMOCLEAR PO/OD

Follow up after 3 months

FBS-125 mg/dl

PLBS- 178

Follow up at the end of thesis

FBS - 122 mg/dl

PLBS-150 mg/dl

Hba1c- 5.9

@⁨Meta AI⁩

Coding: identify initial codes and labels to capture the key concepts and ideas.

Categorization: group the codes into categories and subcategories to organize the data.

Theme identification: identify the emerging themes and patterns in the data.

Theme representation: present the themes as learning points, highlighting the key findings and insights related to To estimate the variability in Clinical, Radiological and Laboratory, therapeutic factors in the spectrum of portal hypertension patients presenting to medicine department and

To assess spectrum of clinical presentations in diabetics with multimorbidities and factors influencing their outcome

And @⁨Meta AI⁩ let us know new insights about the topic and case rather than what we already know

Based on the provided case study, here's an analysis of the key concepts and ideas:

*Initial Codes and Labels:*

1. *Clinical Presentation:* HFPEF (Heart Failure with Preserved Ejection Fraction) with pulmonary edema, renal AKI (Acute Kidney Injury) on CKD (Chronic Kidney Disease), community-acquired pneumonia.

2. *Medical History:* Diabetes Mellitus Type 2, Hypertension.

3. *Medications:* Lasix, Shelcal XT, Nodosis, Orofer XT, Meropenem, Pan, Hai, Cinod, Rosvas CV, Pulmoclear.

4. *Investigations:* RFT (Renal Function Test), LFT (Liver Function Test), ABG (Arterial Blood Gas), USG Abdomen.

5. *Treatment Outcomes:* Patient's condition improved, and was discharged with advice for follow-up.

*Categorization:*

1. *Patient Profile:*

- Medical History

- Medications

- Laboratory results

2. *Clinical Findings:*

- HFPEF with pulmonary edema

- Renal AKI on CKD

- Community-acquired pneumonia

3. *Investigations:*

- Laboratory tests (RFT, LFT, ABG)

- Imaging studies (USG Abdomen)

4. *Treatment and Outcomes:*

- Medications

- Treatment outcomes (patient's condition improved)

*Theme Identification:*

1. *Complexity of Managing Patients with Multimorbidities:* The patient had multiple comorbidities, including diabetes, hypertension, and CKD, which complicated management.

2. *Importance of Comprehensive Care:* The patient required comprehensive care, including management of cardiac, renal, and pulmonary conditions.

3. *Need for Close Monitoring:* The patient's condition required close monitoring, including laboratory tests and imaging studies.

4. *Impact of Treatment on Outcomes:* The patient's condition improved with treatment, highlighting the importance of effective management.

*Theme Representation:*

*Learning Points:*

1. *Early recognition and management of complications* are crucial in patients with multimorbidities.

2. *Comprehensive care* is essential in managing patients with multiple comorbidities.

3. *Close monitoring* of patients with multimorbidities is necessary to prevent deterioration.

4. *Effective management* of patients with multimorbidities can improve outcomes.

*New Insights:*

1. The case highlights the importance of considering the interplay between multiple comorbidities in patient management.

2. The patient's condition may have been influenced by factors such as medication adherence, lifestyle modifications, and underlying disease severity.

3. Further research is needed to understand the relationship between glycemic control and outcomes in patients with multimorbidities.

*Key Findings:*

1. The patient had a complex medical history with multiple comorbidities.

2. The patient's condition improved with comprehensive care and close monitoring.

3. The importance of effective management in patients with multimorbidities.

In the context of the research questions, this case study highlights the variability in clinical presentations and outcomes in patients with multimorbidities, including diabetes and hypertension. The study also emphasizes the importance of comprehensive care and close monitoring in managing patients with complex medical conditions.

The patient's outcome in this case was positive, with improvement in condition and eventual discharge. However, the case also highlights the need for continued follow-up and management to prevent future complications.

In terms of new insights, this case study suggests that a multidisciplinary approach to patient care, including input from nephrologists and other specialists, may be beneficial in managing patients with complex medical conditions. Additionally, the use of evidence-based treatments, such as Lasix and Rosvas CV, may be effective in improving outcomes in patients with HFPEF and CKD.