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