80F HFmEF ; CAD ; DM ; HTN

 Diagnosis

ACUTE PULMONARY EDEMA (RESOLVED) SECONDARY TO HFMEF WITH CAD

PRERENAL AKI

DIABETIS TYPE II

HYPERTENSION

Case History and Clinical Findings

PATIENT CAME WITH CHIEF COMPLAINTS OF DIFFICULTY IN BREATHING SINCE LAST NIGHT.

HOPI -

PATIENT WAS APPARENTLY ASYMPTOMATIC 18 MONTHS BACK THEN SHE DEVELOPED DIFFICULTY IN BREATHING WITH SWELLING OF B/L LOWER LIMBS WITH FACIAL PUFFINESS AND WAS HOSPITALIZED AND TREATED.

C/O DIFFICULTY IN BREATHING SINCE 1 AM LAST NIGHT (GRADE 4 MMRC).

C/O CHEST PAIN - DIFFUSE

ORTHOPNOEA PRESENT, H/O PND PRESENT

NO H/O FEVER, SEIZURES, VOMITING, LOSS OF CONSCIOUSNESS, PALPITATIONS, GIDDINESS, SWEATING, COUGH, COLD.

NO C/O DECREASED URINE OUTPUT, FACIAL PUFFINESS, ABDOMINAL DISTENSION.

PAST HISTORY:

K/C/O HTN SINCE 45 YEARS USING T.OLMESARTAN 20MG BD.

K/C/O DM SINCE 12 YEARS USING T.METFORMIN 500MG BD

K/C/O CAD SINCE 1.5 YEAR USING CLOPIDOGREL 75MG BD

NOT A K/C/O EPILEPSY,TB, ASTHMA.

GENERAL EXAMINATION :

PT IS CONCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .

NO PALLOR, ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY, EDEMA

TEMP - 98.4F

PR- 130 BPM

RR-38 CPM

BP- 180/100MMHG

SPO2 - 85 AT RA

SYSTEMIC EXAMINATION :

CVS - S1,S2 HEARD , NO MURMURS

RS - NO WHEEZE, DYSPNEA PRESENT, VESCULAR BREATH SOUNDS

P/A- SOFT , NON-TENDER , NO ORGANOMEGALY

CNS - NFND

HBsAg-RAPID24-12-2023Negative Anti HCV Antibodies - RAPID24-12-2023Non Reactive RFT 24- 12-2023 UREA68 mg/dlCREATININE1.6 mg/dlURIC ACID8.3 mg/dlCALCIUM10.0 mg/dlPHOSPHOROUS5.2 mg/dlSODIUM134 mEq/LPOTASSIUM5.2 mEq/LCHLORIDE101 mEq/LLIVER FUNCTION TEST (LFT) 24-12-2023 Total Bilurubin0.56 mg/dlDirect Bilurubin0.16 mg/dlSGOT(AST)17 IU/LSGPT(ALT)17 IU/LALKALINE PHOSPHATE124 IU/LTOTAL PROTEINS7.1 gm/dlALBUMIN4.5 gm/dlA/G RATIO1.8COMPLETE URINE EXAMINATION (CUE) 24-12-2023 COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++SUGAR+++BILE SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS3-4RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilABG 24-12-2023 PH7.16PCO227.4PO295.1HCO39.4St.HCO311.1BEB-17.8BEecf-17.5TCO220.8O2 Sat93.7O2 Count13.1PH7.39PCO226.7PO2145HCO315.9St.HCO318.3BEB-7.5BEecf-8.0TCO233.5O2 Sat97.7O2 Count13.3SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 24- 12-2023 SODIUM137 mEq/LPOTASSIUM4.8 mEq/LCHLORIDE104 mEq/LCALCIUM IONIZED1.12 mmol/LSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 24-12-2023 SODIUM138 mEq/LPOTASSIUM3.7 mEq/LCHLORIDE98 mEq/LCALCIUM IONIZED1.18 mmol/LABG 24-12-2023 PH7.49PCO224.9PO262.2HCO318.8St.HCO321.7BEB-3.1BEecf- 4.0TCO238.2O2 Sat93.7O2 Count13.9COMPLETE URINE EXAMINATION (CUE) 24-12-2023 COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilPOST LUNCH BLOOD SUGAR26-12-2023353 mg/dlRFT 26-12-2023 UREA80 mg/dlCREATININE2.1 mg/dlURIC ACID10.9 mg/dlCALCIUM10.1 mg/dlPHOSPHOROUS4.8 mg/dlSODIUM137 mEq/LPOTASSIUM3.7 mEq/LCHLORIDE101 mEq/L

USG ABDOMEN (26-12-23) - NO SONOLOGICAL ABNORMALITY DETECTED

2D ECHO (26-12-23)

GLOBAL HYPOKINESIA, CONCENTRIC LVH

EF:46 %, MODERATE LV DYSFUNCYION

MILD DILATED LA, LV

MODERATE MR+, AR+, MILD TR+ WITH PAH

SPECKS OF CALCIFIED TRILEAFLETS (AV)

THICKENED MV

RVSP 33+10MMHG

IVC SIZE 0.9CM

Treatment Given :

FLUID RESTRICTION <1.5 LITRES/DAY

SALT RESTRICTION <2-3 G/DAY

INJ. MONOCEF 1G IV/BD X 6DAYS

INJ. LASIX 40MG IV BD

TAB. GLICLAZIDE 80MG OD

TAB. MET-XL 50MG OD

TAB. ECOSPIRIN GOLD 75/75/10

TAB ULTRACET PO BD

TAB. SPINFREE BD

TAB PREGABA-M 75MG PO HS

TAB DYTOR 10/50 PO OD

SYP LACTULOSE 15ML TID

SYRUP MUCAINE GEL 10ML TID

7 POINT GRBS MONITORING

STRICT I/O CHARTING

VITALS MONITORING 4TH HRLY

Advice at Discharge

FLUID RESTRICTION <1.5 LITRES/DAY

SALT RESTRICTION <2-3 G/DAY

TAB. GLICLAZIDE 80MG OD X 1MONTH

TAB. MET-XL 50MG ODX 1MONTH

TAB. ECOSPIRIN GOLD 75/75/10 X 1MONTH

TAB ULTRACET PO BD X 2 DAYS

TAB. SPINFREE BD X 2 DAYS

TAB PREGABA-M 75MG PO HSX 1MONTH

TAB DYTOR 10/50 PO ODX 1MONTH

SYP LACTULOSE 15ML TIDX 1MONTH

SYRUP MUCAINE GEL 10ML TIDX 1MONTH

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