43F Diabetes on insulin 10 yrs, Hypothyroid 6yrs, HTN bilateral pedal edema 4 months

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05 November 2024

PaJR PHR Moderator: Reviewing her in OPD now

Participant: Presenting complaints?

PaJR PHR Moderator: Her EMR summary for your updated case report 👇

Age/Gender : 45 Years/Female
Discharge Type: Relieved
Admission Date: 21/10/2024 01:32 PM

Diagnosis
  1. ACUTE PULMONARY PEDEMA SECONDARY TO CKD WITH DIABETIC NEPHROPATHY
  2. HEART FAILURE WITH PRESERVED EJECTION FRACTION(EF56%)
  3. WITH ANEMIA OF CHRONIC DISEASE
  4. K/C/O DM2 SINCE 15 YRS
  5. K/C/O HTN SINCE 10 YRS
  6. K/C/O HYPOTHYROIDISM SINCE 1YR
Case History and Clinical Findings
  • PT WAS BROUGHT TO THE CASUALTY WITH C/O BREATHLESSNESS SINCE 2 DAYS
  • HOPI: PT WAS APPARENTLY NORMAL 2 DAYS BACK THEN SHE DEVELOPED BREATHLESSNESS GRADE 2 MMRC INITIALLY AND GRADUALLY PROGRESSED TO GRADE 4 ASSOCIATED WITH COUGH WITH EXPECTORATION - GREENISH MUCOID SPUTUM SINCE 4 DAYS.
  • FEVER SINCE 4 DAYS-HIGH GRADE, INTERMITTENT, ASSOCIATED WITH CHILLS AND RIGORS AND RELIEVED BY MEDICATION
  • C/O B/L SWELLING OF LOWER LIMBS - PITTING TYPE, EXTENDED UPTO THE KNEE SINCE 1 YR (ON AND OFF)
  • C/O DECREASED URINE OUTPUT SINCE 1 YR - VERY MUCH REDUCED SINCE 3 DAYS
  • C/O ABDOMINAL DISTENSION SINCE 4-5 MONTHS, ORTHOPNEA PRESENT
  • NO C/O CHEST PAIN, PALPITATIONS, PND, SWEATING, GIDDINESS
History
  • K/C/O DM2(SINCE 15 YRS) INITIALLY STARTED INSULIN BUT NOW ON OHAS - SITAGLIPTIN 50 & METFORMIN 1000 & GLIMIPERIDE2
  • K/C/O HTN SINCE 10 YRS USING T.PRAZOSIN 5MG
  • K/C/O HYPOTHYROIDISM SINCE 1 YR USING T.THYRONORM 150MCG
  • K/C/O CKD SINCE 1 YR ON CONSERVATIVE MANAGEMENT
  • NOT K/C/O CVA, CAD, TB, EPILEPSY, ASTHMA
  • GENERAL EXAMINATION-PT IS C/C/C
  • PALLOR, EDEMA PRESENT(PITTING TYPE), NO ICTERUS CYANOSIS LYMPHADENOPATHY
  • BP-240/100MMHG
  • PR112BPM RR42CPM
  • SPO2 67% AT RA GRBS 100MG%
  • SYSTEMIC EXAMINATION
  • CVS: INSPECTION-JVP NOT RAISED, CHEST WALL SHAPE NORMAL AND SYMMETRICAL, NO DILATED VEINS/SCARS, KYPHOSCOLIOSIS ABSENT
  • PALPATION - APICAL IMPULSE NORMAL NO PARASTERNAL HEAVE, NO THRILLS PERCUSSION - DULL NOTE PRESENT
  • AUSCULTATION-S1S2 PRESENT, NO MURMURS
  • RESPIRATORY SYSTEM: BAE PRESENT, NVBS, DIFFUSE CREBS PRESENT P/A: SOFT, NON TENDER, NO ORGANOMEGALY
  • CNS: NO FOCAL NEUROLOGICAL DEFICITS
Course in Hospital 

PT WAS BROUGHT TO CASUALTY ON 21/0/2024 AT 1:30 PM WITH H/O SEVERE SOB ON EXAMINATION PR 112 BPM, BP 240/ 100 MMHG, RR 42CPM,SPO2 61% AT RA, ON AUSCULATION DIFFUSE FINE CREPS PRESENT IN ALL LUNG FIELDS, IMMEDIATELY PT WAS GIVEN 10 LIT OF O2 GIVEN, INJ LASIX 80 MG IV STAT GIVEN, IMJ NTG 1CC IV STAT GIVEN, AND OBSERVED FOR 5 MINS WITH O2 SATURATION 90% AND PT KEPT ON CONTINUOUS CPAP AND PT SHIFTED TO ICU THERE PT GIVEN ANTIHYPERTENSIVE TREATMENT AND HYOOGLYCEMIC AGENTS AND KEPT UNDER OBSERVATION AND AT 5PM PT BP IS 190/100 MMHG, PR IS 98 BPM, RR 30 CPM, SATURATION 98% WITH CPAPA, DIFFUSE CREPS PRESENT ON ASCULATION AGAIN INJ NTG 1CC IV GIVEN AND LASIX 40 MG GIVEN AT 8 PM BP 180/100 MMHG PR 100BPM, RR 20 CPM AND SPO2 100 ON CPAP AND ADVISED INTERMITTENT CPAP WITH O2 SUPPORT WAS GIVEN. 
ON 22/10/24 BP WAS 130/70MMHG, PR 86 RR 18 CPM SPO2 98% WITH 6 LIT O2 AND CONTINUED LASIX 40 MG BD GIVEN, PRAZOSIN 500MG, TAB.OLKEM TRIO, INJ AUGMENTIN 1.2 G, PT CONDITION IMPROVED AND WAS KEPT ON 4 LIT O2 AND CONTINUED SAME CONDITION ON 24 /10/2024 SAME TREATMENT WAS CONTINUED PT CONDITION IMPROVED ON AUSCULTATION B/L LUNG FEILDS ARE CLEARED AND CONTINUED ON INTERMITTENT O2 WITH NASAL PRONGD AT RATE OF 2 LIT/ MIN AND ADVISED DISCHARGE.

Investigation

Arterial Blood Gas (ABG):

  • pH: 7.38
  • PCO₂: 32.2
  • PO₂: 158
  • HCO₃: 19.0
  • St. HCO₃: 20.3
  • BEB: -5.0
  • BEecf: -5.1
  • TCO₂: 41.3
  • O₂ Sat: 99.3
  • O₂ Count: 9.5

Kidney Function Tests:

  • Blood Urea:
    • First Test: 70 mg/dL (Reference: 12-42 mg/dL)
    • Second Test: 88 mg/dL
  • Serum Creatinine:
    • First Test: 1.9 mg/dL (Reference: 0.6-1.1 mg/dL)
    • Second Test: 1: 2.0 mg/dL
    • Third Test: 2: 1.5 mg/dL

Serum Electrolytes (Na, K, Cl):

  1. First Test:

    • Sodium: 130 mmol/L (Reference: 136-145 mmol/L)
    • Potassium: 3.7 mmol/L (Reference: 3.5-5.1 mmol/L)
    • Chloride: 101 mmol/L (Reference: 98-107 mmol/L)

  2. Second Test:

    • Sodium: 132 mmol/L
    • Potassium: 3.5 mmol/L
    • Chloride: 102 mmol/L

  3. Third Test:

    • Sodium: 134 mmol/L
    • Potassium: 3.3 mmol/L
    • Chloride: 103 mmol/L

  4. Fourth Test:

    • Sodium: 135 mmol/L
    • Potassium: 3.6 mmol/L
    • Chloride: 98 mmol/L

Liver Function Test (LFT):

  • Total Bilirubin: 0.60 mg/dL
  • Direct Bilirubin: 0.19 mg/dL
  • SGOT (AST): 29 IU/L
  • SGPT (ALT): 20 IU/L
  • Alkaline Phosphatase: 110 IU/L
  • Total Proteins: 5.8 gm/dL
  • Albumin: 3.0 gm/dL
  • A/G Ratio: 1.06

Hepatitis Screening:

  • HBsAg (Rapid): Negative
  • Anti-HCV Antibodies (Rapid): Non-Reactive

Complete Urine Examination (CUE):

  • Color: Pale yellow
  • Appearance: Clear
  • Reaction: Acidic
  • Specific Gravity: 1.010
  • Albumin: ++
  • Sugar: Nil
  • Bile Salts: Nil
  • Bile Pigments: Nil
  • Pus Cells: 4-6
  • Epithelial Cells: 2-3
  • Red Blood Cells: Nil
  • Crystals: Nil
  • Casts: Nil
  • Amorphous Deposits: Absent
  • Others: Nil

Thyroid Profile:

  • T3: 0.36 ng/mL
  • T4: 15.17 µg/dL
  • TSH: 5.4 µIU/mL
Treatment Given (Enter only Generic Name)
  • INTERMITTENT C-PAPFLUID
  • RESTRICTION LESS THAN 1LIT/DAY
  • SALT RESTRICTION LESS THAN 2-3GMS/DAY
  • INJ NTG 1CC IN 4ML NS ICC IV STAT
  • INJ.LASIX 40MG IV BD
  • INJ.HAI S/C TID ACCORDING TO GRBS
  • T.PRAZOSIN 5MG PO/OD
  • T.THYROXIN 150MCG PO/OD BEFORE BREAKFAST
  • NODOSIS 500MG PO/OD
  • T.OLKEN TRIO PO/OD
  • INJ.AUGMENTIN 1.2GM IV TID
  • SYP ASCORYL LS 10ML PO/TID
  • T.VYMADA 50MG PO/BD
  • T.VYSOV-D 100/10 PO/OD
Advice at Discharge

Dietary Restrictions:

  • Fluid Restriction: Less than 1 lit/day
  • Salt Restriction: Less than 2-3 gms/day

Medications:

  • Inj HAI S/C: 6 units BD 8 AM and 8 PM before food
  • Tab Augmentin 625 mg: PO/BD x 3 days
  • Tab Lasix 40 mg: BD x 15 days
  • Tab Vysov D 100/10: PO/OD x 15 days (1 PM)
  • Tab Vymada 50 mg: PO OD x 15 days
  • Tab Prazosin 5 mg: PO OD x 15 days
  • Tab Olkem Trio: PO OD x 15 days
  • Tab Nodosis 500 mg: PO BD x 15 days
  • Tab Thyronorm 150 mcg: PO OD to be continued
  • Tab PAN 40 mg: PO OD
  • Syp Ascoril LS 10 ml: PO BD x 5 days
  • T.Shelcal XT: PO OD at 2 PM for 15 days
  • Monitor Glucose At Home: Check using a Glucometer at 7 AM, 10 AM, 4 PM, 10 PM
Follow Up:
Review to GM OPD SOS

When to Obtain Urgent Care:
In case of any emergency, immediately contact your consultant doctor or attend the emergency department.

Preventive Care:
  • Avoid self-medication without doctor's advice.
  • Do not miss medications.
In case of Emergency or to speak to your treating faculty or for appointments, please contact _____________.

For Treatment Inquiries Patient/Attendant Declaration:
The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language.

Discharge Date Date: 25/10/24

PaJR PHR Moderator:

OPD review post discharge 11 days from ICU where she was
admitted with severe heart failure secondary to her
metabolic syn with Diabetes since 12 years


Trunkal obesity and sarcopenia phenotype

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