63M with Type 1 Respiratory failure with cardiogenic pulmonary edema with CKD , HTN , DM2
DOA : 6/1/2023
Discharge
Date: 11/1/23
Ward: MMW
Unit: GM 5
Diagnosis
TYPE 1 RESPIRATORY FAILURE WITH CARDIOGENIC PULMONARY EDEMA WITH K/C/O CKDWITH K/C/O HTN + , DM TYPE 2 + &OHA INDUCED HYPOGLYCEMIA
Case History and Clinical Findings
Chief complaints : Difficulty in breathing since yesterday morning
Patient was apparently asymptomatic since 30 years. He then had burning sensation in feet and wentto hospital. Necessary investigations were done and diagnosed with diabetes mellitus 2 andhypertension .with 150/100mmhg On metformin for 27 years , amlodipine 10mg
Burning sensation of feet and fatigue went to hospital at Nalgonda again three years ago . Wasadvised insulin. 30u morning and 15u night used for one year still uncontrolled diabetes so changedto mixtard 25u morning and 20u at night, later changed to 20u morning and 15u night since 2 years .Alongwithinsulinalsoaddedgliclazideextendedreleasetablets60mg(recluse-XR60)butdefaulter.
Five years ago had UTI renal calculi post surgery was uneventful. Post surgery 8 monthsInvestigations showed increase in creatine levels 1.6-2.0. Tab nodosis and uremax (sodiumbicarbonate)500mg -2000mg per day on increased creatine levels >2.<2 1000mg
Three years ago left hand weakness mouth deviation slurred speech mri brain was done andmedications were given
Attacks of giddiness , unstable gait, swaying gait and slurred speech came to kamineni neuro opdMRI brain was done in 2021. ?hemorrhagic clot and medicines were prescribed.
Two years ago had an episode of epilepsy due to ?hypoglycemic episode was advised Ecospirin150/70mg H/S.
Bilateral pedal edema pitting type present, burning micturition, decreased urine output, SOB grade 4spo2 75% at room air. Fever at night not associated with chills and rigor , relived after one hour ontaking Dolo 650mg taken , after one hour again had episode of fever, relived after one hour of takingDolo 650mg. Cough with expectoration present.
Left limited mobility and pain on shoulder movement.
MEDICAL HISTORY:
* She is under medication ( MET XL - metoprolol and inj. Human mixtard , tab. Aspirin, tab. Clopitab
)Not a K/C/O asthma / Ischemic heart disease / epilepsy / TB
FAMILY HISTORY:No significant familyhistory
PERSONAL HISTORY
OCCUPATION : House wifeDIET : MixedAPPETITE : NormalSLEEP :NormalBOWEL AND BLADDER HABITS : NormalADDICTIONS: No
GENERAL EXAMINATION*
Patient is concious coherent and coperative, well oriented to time palce and person* Built -moderately built , moderately nourishedVITALSBlood pressure: 130/60 mm hgPulse Rate: 95bpmRR: 27 cpmTemperature: 99.5 degrees FSPO2: 91% under 8L of O2EDEMA OFFEET:PRESENT ; PITTING TYPE*NO PALLOR,ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM :
Inspection : bilateral symmetrical chest
Palpation: trachea centrally placed, bilateral symmetrical chest movementsPercussion: resonance
Auscultation: diffused wheezes and crepts in left and right sides of chestPER ABDOMEN :
Inspection: distendedPalpation:softnontender
Auscultation: bowel sounds heardPercussion: shifting dullness presentCVS:
S1 S2 heard, JVP raisedCNS:
no focal deficit
COURSE IN THE HOSPITAL :
62 year old male was bought to casualty with above mentioned complains. At the time of admissionhis vitals were bp : 160/90 mm hg, RR: 35 cpm on examination respiratory - diffused creptsCVS-s1s2JVP raisedBilateral pitting pedal edema Managed with inj Lasix40mg and his abg showed dercresedpo2 &pco2 ; diagnosed as type 1 respiratory failure and managed with cpap with community acquiredpneumoniaSymptoms subsided.patient hemodynamically stable and planned for discharge
Rr trends :
on 6/1/23 - 35 cpmon 7/1/23 - 24 cpmon 8/1/23 - 16 cpmon 9/1/23 - 18 cpmon 10/1/23 - 20 cpmon 11/1/23 - 20 cpmgrbs trends :
on 6/1/23
10 pm - 127 mg/dl12 am - 130mg/dl2 am - 127mg/dl
4 am - 190 mg/dlon 7/1/23
8 am - 183 mg/dl
4 pm - 289 mg/dl
8 pm - 258 mg/dl
10 pm -127 mg/dl
4 am - 97 mg/dlon 8/1/23
8 am - 125 mg/dl
10 am - 276 mg/dl
12 pm - 262 mg/dl
4 pm - 171 mg/dl
8 pm - 193 mg/dl
10 pm - 462 mg/dl
12 am - 353 mg/dl
2 am - 179 mg/dlon 9/1/23
8 am - 181 mg/dl2pm - 495 mg/dl4 pm -201 mg/dl
8 pm - 105 mg/dlon 10/1/23
8 am - 200 mg/dlon 11/1/23
8 am :152 mg/dl
Nephro opinion was taken and advice followedPulmo opinion was taken and advice followedOptho opinionwas taken and advice followedDac opinionwas taken and advice followedInvestigation
2D ECHO -
EF : 58 %
RUSP : 30 MM HGCONCLUSION :
MILD AR+, TRIVIAL TR+ | NO MR
NO RWMA NO AS/MS, SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION. NO PAH/PECBNAAT OF SPUTUM - NEGATIVE
RAT FOR COVID - NEGATIVE
C/S OF SPUTUM - ZN STAIN: NO ACID FAST BACILLI SEEN
GRAM STAIN: >30 EPITHELIAL CELLS/CPF, 2-3 PUS CELLS/CPF &GRAM POSITIVE COCCI INSINGLES, PAIRS, CHAINS , FEW GRAM POSITIVE BACILLI AND FEW GRAM NEGATIVE BACILLINORMAL OROPHARYNGEAL FLORA GROWN
Treatment Given(Enter only Generic Name)
Restriction of fluid <1.5 lts/ dayRestriction of salt <2 gm/dayInj.lasix 40 mg Iv/bdIntermittentCPAPSalbutamol nebulization 8th hrlyT.Nodosis 500 mg po/bdT.Shelcal 500 mg po/bdT.Carvedilol3.125mg po/bdCap.Bio d3 po/OD weekly onceHAI acc to grbsInj.piptaz 225 mg IV/TIDSyrupCremaffin 15ml po/TidT.Ultracet po /Qid
Advice at Discharge
T augmentin 650mg po/BD *5daysT nodosis 500mg po/BD *7 daysT shelcal po/OD at 2pm *7daysTmvt po/od *7daysCap Bio D3 po/ weekly onceSyrup ascoril ls 2tsp po Syrup cremaffin 15ml po/tid
*7daysInsulin HAI s/c8-8-6units before foodHome GRBS monitoring
