Case 23. 65 male with involuntary movements

DoA 10/3/24

Dod 15/3/24

Diagnosis

CARDIOGENIC PULMONARY EDEMA SECONDARY TO CAD

HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF 40%)

K/C/O CKD SINCE 1 YR

K/C/O DM 2 SINCE 10 YEARS

Case History and Clinical Findings

C/O SHORTNESS OF BREATH SINCE YESTERDAY 10PM

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 10PM YESTERDAY SUDDENLY SHE

HAD SHORTNESS OF BREATH WHICH IS SUDDEN IN ONSET GRADUALLY PROGRESIVE

(GRADE 2 NYHA ) NO H/O FEVER, COUGH, COLD, VOMITINGS, DIARRHOEA, BURNING

MICTURITION, DECREASE IN URINE OUTPUT SHE HAD SIMILAR COMPLAINTS ON 1/3/24 AND

ADMITTED IN GOVERNAMENT HOSPITAL AND TREATED THERE DISCHARGED ON 3/3/24 AND

THEN SHE RECOVERED

K/C/O CKD WITH DIABETIC NEPHROPATHY AND ADMITTED IN OUR HOSPITAL WITH

COMPLAINTS OF VOMITINGS AND EPIGASTRIC PAIN ON 16/9/23 AND DISCHARGED ON

19/9/24

PAST HISTORY

K/C/O DM SINCE 10YRS ON TAB GLIMI M1 PO/OD NOT USING ANY MEDICATION SINCE NOV

2023

NO H/O DM, TB, ASTHMA. HTN, EPILEPSY

GENERAL EXAMINATION

PT IS C/C/C

TEMP - 98.6F

PR - 130BPM

RR - 30CPM

BP - 130/80MMHG

SPO2 - 86% @ RA

GRBS - 464MG %

SYSTEMIC EXAMINATION

CVS - S1, S2 +, NO MURMURS

CNS - NFND

RS - B/L DIFFUSE FINE CREPTS PRESENT

P/A - SOFT NONTENDER

PULMO REFERAL WAS DONE I/V/O ? PULMONARY TB

AND ADVISED TO REVIEW WITH REPORTS

COURSE IN THE HOSPITAL

50 YR OLD FEMALE FARMER BY OCCUPATION K/C/O DM 2 SINCE 10 YRS K/C/O CKD WITH

DIABETIC NEPHROPATHY SINCE 6 MONTHS WHO IS ON IRREGULAR MEDICATION CAME

WITH C/O SOB AND ON ADMISSION VITALS WERE

TEMP - 98.6F

PR - 130BPM

RR - 30CPM

BP - 130/80MMHG

SPO2 - 86% @ RA

GRBS - 464MG %

6UNITS OF IV INSULIN WAS GIVEN AND NECCESSARY INVESTIGATIONS WERE DONE HRCT

SHOWED -

-BILATERAL CENTRAL / PERIHILAR AIR SPACE OPACITIES FEATURES SUGGESTIVE OF

PULMONARY EDEMA

SEGMENTAL ATELECTASIS IN B/L LUNG LOWER LOBES

B/L MODERATE PLEURAL EFFUSION

MULTIPLE CYSTS IN BOTH KIDNEYS

AND TROPONIN I 130.3PG/ML AND DIAGNOSED TO BE

CARDIOGENIC PULMONARY EDEMA SECONDARY TO CAD

HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF 40%)

K/C/O CKD SINCE 1 YR

K/C/O DM 2 SINCE 10 YEARS AND STARTED ON ANTIBIOTICS, ECOSPIRIN, INJ HAI

ACCORDING TO GRBS, INJ LASIX AND NEB WITH IPRAVENT 6TH HOURLY , BUDECORT 8TH

HOURLY PULMONOLOGY REFERRAL WAS DONE AND ADVISED CONTINUE SAME

TREATMENT AND PATIENT IMPROVED SYMPTOMATICALLY AND DISCHARGED IN

HEMODYNAMICALLY STABLE CONDITION

Investigation

ABG 10-03-2024 09:10:AMPH 7.351PCO2 20.0PO2 116HCO3 10.8St.HCO3 14.1BEB -13.2BEecf -

13.8TCO2 22.8O2 Sat 94.6O2 Count 13.0

BLOOD UREA 10-03-2024 108 mg/dl SERUM CREATININE 10-03-2024 3.4 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 10-03-2024 SODIUM 141 mmol/L POTASSIUM 5.6 mmol/L

CHLORIDE 106 mmol/L HBsAg-RAPID 10-03-2024 Negative

Anti HCV Antibodies - RAPID 10-03-2024 Non Reactive

FBS # 477mg/dLPOST LUNCH BLOOD SUGAR 10-03-2024 321 mg/dl

BLOOD GROUP RH TYPING : B POSITIVE (+VE)

HEMOGRAM 10-03-2024

HAEMOGLOBIN # 9.6 gm/dlTOTAL COUNT # 14,800 cells/cummRBC COUNT 3.85

millions/cummPLATELET COUNT 4.70 lakhs/cu.mmIMPRESSION :Normocytic normochromic

anemia with neutrophilic leukocytosis and thrombocytosis .

SERUM IRON 54ug/dl

URINE FOR KETONE BODIES: NEGATIVE(-VE)

FBS 84 mg/dl

PLBS 134 mg/dl

Hba1C 5.8 %

LIVER FUNCTION TEST (LFT) 10-03-2024 Total Bilurubin 1.14 mg/dl Direct Bilurubin 0.17 mg/dl

SGOT(AST) 12 IU/L SGPT(ALT) 11 IU/L ALKALINE PHOSPHATASE 245 IU/LTOTAL PROTEINS

7.9 gm/dl ALBUMIN 3.55 gm/dl A/G RATIO 0.82COMPLETE URINE EXAMINATION (CUE) 10-03-

2024 COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN

++++SUGAR +BILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED

BLOOD CELLS plentyCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

SERUM ELECTROLYTES (Na, K, C l) 10-03-2024 SODIUM 137 mmol/L POTASSIUM 4.8 mmol/L

CHLORIDE 99 mmol/L BLOOD UREA 11-03-2024 05:19:AM 125 mg/dl

HEMOGRAM

HAEMOGLOBIN # 8.0gm/dl

TOTAL COUNT # 15,500 cells/cummRBC COUNT # 3.28 millions/cummPLATELET COUNT 4.0

lakhs/cu.mmIMPRESSION : Normocytic normochromic Anemia with Leukocytosis.

SERUM CREATININE 11-03-2024 3.4 mg/dl SERUM ELECTROLYTES (Na, K, C l) 11-03-2024

SODIUM 141 mmol/L POTASSIUM 4.5 mmol/L CHLORIDE 105 mmol/L

TROPONIN-I # 130.3 pg/ml

T3, T4, TSH 11-03-2024 T3 0.51 ng/ml T4 13.42 micro g/dl TSH 0.96 micro Iu/ml lBLOOD UREA 11-

03-2024 120 mg/dl l

SERUM CREATININE 11-03-2024 3.4 mg/dl SERUM ELECTROLYTES (Na, K, C l) 11-03-2024

SODIUM 137 mmol/L POTASSIUM 3.8 mmol/L CHLORIDE 102 mmol/L

HAEMOGLOBIN# 8.1gm/dlTOTAL COUNT# 12,600cells/cummRBC COUNT #

3.16millions/cummPLATELET COUNT 3.72lakhs/cu.mmIMPRESSION Normocytic normochromic

Anemia with Leukocytosis.

24H URINE PROTEIN/CREATININE RATIO

24 HOURS URINE PROTEIN 480 mg/day.

24 HOURS URINE CREATININE 0.9g/dayRATIO 0.53URINE VOLUME 2,000ml

HEMOGRAM 12-03-2024

HAEMOGLOBIN# 8.1gm/dl

TOTAL COUNT# 12,600cells/cummRBC COUNT# 3.16millions/cummPLATELET

COUNT3.72lakhs/cu.mmIMPRESSIONNormocytic normochromic Anemiawith Leukocytosis.

BLOOD UREA 12-03-2024 111 mg/dl SERUM CREATININE 12-03-2024 3.6 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 12-03-2024 SODIUM 140 mmol/L POTASSIUM 3.9 mmol/L

CHLORIDE 98 mmol/L

USG ABDOMEN

IMPRESSION - B/L RENAL CORTICAL CYST

B/L GRADE 3 RPD CHANGES IN KIDNEYS

B/L MILD TO MODERATE PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE AND

CONSOLIDATORY CHANGES

2DECHO

RWMA +

MILD AR +, MODERATE MR + WITH PAH

MODERATE LV DYSFUNCTION PRESENT

GRADE 1 DIASTOLIC DYSFUNCTION

MINIMAL PE +, PLEURAL EFFUSION PRESENT

BLOOD C/S REPORT : NO GROWTH AFTER 48 HOURS OF AEROBIC INCUBATION.

URINE C/S REPORT: NO BACTERIAL GROWTH.

HRCT CHEST

-BILATERAL CENTRAL / PERIHILAR AIR SPACE OPACITIES FEATURES SUGGESTIVE OF

PULMONARY EDEMA

SEGMENTAL ATELECTASIS IN B/L LUNG LOWER LOBES

B/L MODERATE PLEURAL EFFUSION

MULTIPLE CYSTS IN BOTH KIDNEYS

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5 L /DAY

SALT RESTRICTION <2G/DAY

TAB AUGMENTIN 625MG PO/BD

TAB CLINDAMYCIN 600MG PO/BD

INJ HAI SC /TID 5 UNITS

TAB LASIX 40MG PO/BD

NEB WITH IPRAVENT 6TH HOURLY , BUDECORT 8TH HOURLY

TAB NODOSIS 500MG PO/BD

TAB METFORMIN + VILDAGLIPTIN 500/50 PO/BD

TAB OROFER XT PO/OD

TAB SHELCAL 500MG PO/OD

TAB MET-XL 12.5MG PO/OD

TAB ECOSPIRIN GOLD PO/HS

Advice at Discharge

FLUID RESTRICTION <1.5 L /DAY

SALT RESTRICTION <2G/DAY

INJ HAI SC /TID 5 UNITS 8AM 5U----1PM 5U---8PM 5U

TAB LASIX 40MG PO/OD ONCE DAILY AT 8 AM

TAB NODOSIS 500MG PO/BD TWICE DAILY

TAB METFORMIN + VILDAGLIPTIN 500/50 PO/OD ONCE DAILY

TAB OROFER XT PO/OD ONCE DAILY 2PM

TAB SHELCAL 500MG PO/OD ONCE DAILY 2 PM

TAB MET-XL 12.5MG PO/OD ONCE DAILY 8 AM

TAB ECOSPIRIN GOLD PO/HS AT NIGHT HALF HOUR(1/2) BEFORE SLEEP AT NIGHT

Follow up in september 2024

FBS 124 mg/dl

PLBS 138 mg/dl

Hba1C 6.3%

Follow up in january 2025

FBS 111 mg/dl

PLBS 145 mg/dl

Hba1c 5.9%