37 M with dyspnea with history of pedal edema
A 37 year old male came to opd with c/o shortness of breath grade 4 since 3 months .
HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 2 years back ,
then the patient had an episode of giddiness ?due to shock (from the death of his brother in law) ,for which he went to a local hospital and got diagnosed with hypertension.
Since then the patient was started on increasing doses of Telma and later Telma -H, but the patient was not compliant to the medication. He used to take the medication only when there's occasional neck stiffness and pain.
History of mild shortness of breath and chest pain 3 months back, not associated with cough, fatigue for which he went to a local hospital where patient was started on cilnidipine.
Since then complaints were on and off but did not subside.
Sob worsened since one month to grade 4 , associated with mild b/l pedal edema , non pitting, upto knees
H/o fever 20 days back, associated with cough and weight loss (patient's waist size reduces from 32 to 28 in the span of 1 month)
Then patient came to our hospital with grade 4 sob and got admitted.
Extended personal history:-
37 yrs old male elder son of his family who studied till 9th standard later he discontinued because of financial issues there after he started his own business at the age of 12yrs( paper recycling) runned for about 3yrs and discontinued because of loss in his business and returned to his grown up place there after for about 1-2yrs he went for farming with his parents and later because in need of more money he started working as lorry cleaner( as he do overnight work and feel tired he started getting habituated to drink alcohol and smoking)in the gap of 2 yrs he learned how to drive and he continued as lorry driver( he returns to home once in a week, used to continuously drink alcohol more than a full bottle with dec intake of food, in between a week too she used to drink).After 8yrs (2014) he got married later after this children were born he discontinued as lorry driver and started working as daily labourer where he used to lift heavy weights after doing work to overcome his tiredness he used to drink alcohol (180ml/day). one fine day (in the year of 2020) he went to his sister house(family gathering),there was an incident of sudden death of his brother in law he became very anxious( as his sister lost his husband in young age) and weak when he got his first bp check ( 190/110) he was prescribed anti htn but he refused to take it regularly( as there is a misnom in his village not to take antihtn in a very young age) and to overcome his sorrowness he started taking much more alcohol and smoking very regularly.
All his present complaints started since the month of November (2021) where he first noticed pedal edema and sob on exertion
PAST HISTORY:-
No similar complaints in the past (before 2 years) No significant medical or surgical history
Not a known case of DM, bronchial asthma, CAD, Epilepsy
FAMILY HISTORY:-
No family history of HTN, DM, bronchial asthma, epilepsy
Addictions:-
Patient is a chronic alcoholic and chronic smoker since 15 years
Alcohol 90-150 ml per day whiskey/brandy
1-2 beedi per day for 15 years
General examination:-
Patient is conscious,coherent , cooperative,
Oriented to time , place and person
Pallor present
No signs of icterus, lymphadenopathy.
Mild Pedal edema present in both legs
Temp:- 98.3 F
BP:- 190/120 mmhg
RR:- 20 cpm
PR:- 85 bpm
Systemic examination:-
CVS- S1, S2 heard,
parasternal heave grade 2,
diffuse apex beat (right ventricular apex)
no palpable P2
Raised jvp, no thrills, no tender points
Respiratory system:- BAE + , Nvbs heard
P/A :- soft, non tender, no orgamomegaly
CNS - NAD
Investigations:-
BGT- A positive
Hb- 7 g/dl
Na+ - 136 mEq/l
K+ - 4.9 mEq/l
Cl- 107 mEq/l
Sr. Creatinine - 4.3 mg/dl
LFT:-
TB - 0.95
DB- 0.20
AST- 30
ALT- 17
ALP -108
TP- 5.0
Alb- 1.4
A/G ratio - 0.24
Blood urea - 115 mg/dl
ECG shows left ventricular hypertrophy SV1+RV6 = 39mm
Chest x-ray suggesting mild pleural effusion and prominent right descending pulmonary artery ? pulmonary hypertension with cardiomegaly
Treatment:-
1) T. NICARDIA 10 MG SOS
2) STRICT BP MONITORING HOURLY
3) T. ULTRACET 1/2 TAB SOS
4) Fluid and salt restriction
23/2/22
Day 2
S- Sob slightly reduced, pedal edema resolved
O- Patient is conscious, coherent, cooperative
Pallor present
No signs of icterus, cyanosis, lymphadenopathy, pedal edema
BP- 140/90 mmhg
PR- 80 bpm
RR- 20 cpm
CVS- S1,S2 heard, parasternal heave grade 2,
diffuse apex beat (right ventricular apex)
no palpable P2
Raised jvp, no thrills, no tender points.
Respiratory system:- BAE + , Nvbs heard
P/A :- soft, non tender, no orgamomegaly
CNS - NAD
A:- Chronic renal failure secondary to Hypertensive nephropathy(?Renal artery stenosis)
P:-
1)TAB. NICARDIA 10 MG PO / SOS (if SBP >/_150 mmhg)
2)TAB ULTRACET 1/2 TAB TID 1/2----1/2----1/2
3)BP MONITORING 4th HOURLY
4)INJ. LASIX 40 mg IV SOS
5)FLUID AND SALT RESTRICTION.
12 hour BP charting
|
TIME |
BP(mmhg) |
|
8pm |
190/120( NICARDIA 10mg) |
|
9pm |
170/120 (NICARDIA 10mg) |
|
10pm |
130/90 |
|
11pm |
140/90 |
|
12am |
120/80 |
|
1am |
120/80 |
|
2am |
120/80 |
|
3am |
130/80 |
|
6am |
140/90 |
|
8am |
140/90 |
Patient sent for Renal artery Doppler and 2D echo
24/2/22
AMC
AMC
37/M
S- Difficulty in sleeping last night due to sob, pedal edema resolved. No c/o generalized weakness
O- Patient is conscious, coherent, cooperative
Pallor present
No signs of icterus, cyanosis, lymphadenopathy, pedal edema
BP- 190/100 mmhg
PR- 80 bpm
RR- 20 cpm
CVS- S1,S2 heard, parasternal heave grade 2,
diffuse apex beat (right ventricular apex)
no palpable P2
Raised jvp, no thrills, no tender points.
Respiratory system:- BAE + , Nvbs heard
P/A :- soft, non tender, no orgamomegaly
CNS - NAD
Fundoscopy done yesterday.
Impression:-
Right eye- Grade 1 Hypertensive retinopathy
Left eye- Grade 2 Hypertensive retinopathy
Renal artery Doppler done yesterday.
Impression:-
- Bilateral grade 3 renal parenchymal disease
- Raised AT value and low AI value suggestive of Chronic Renal Parenchymal disease.
Ultrasound abdomen and pelvis done.
Impression:-
- B/L grade 3 Renal parenchymal disease
- Mild ascites with mild to moderate pleural effusion.
CUE - Albuminuria present
24 hr UPCR sent
24 hr urinary protein - 1,190 mg/day
24 hr urinary sodium- 227 mmol/day
24 hr urine volume 1300ml
Serum Uric acid- 7.5 mg%
Serum electrolytes Na - 140, Cl 106, K+ 5
Serum creatinine- 5.6 mg/dl
Serum calcium- 9mg/dl
Blood urea - 119 mg/dl
2D echo:- All chambers dilated.
A:- HFpeF with CKD ? Primary glomerular disease
P:-
1)TAB. NICARDIA 10 MG PO / SOS (if SBP >/_150 mmhg)
2)TAB ULTRACET 1/2 TAB TID 1/2----1/2----1/2
3)BP MONITORING 2nd HOURLY
4)INJ. LASIX 40 mg IV SOS
5)FLUID AND SALT RESTRICTION.
6)Adding long acting antihypertensives and preload reducing agents.
|
TIME |
BP (mmhg) |
|
2pm (23/2/22) |
150/120 |
|
4pm |
140/100 |
|
6pm |
140/90 |
|
8pm |
160/100 |
|
10pm |
170/110 |
|
12am (24/2/22) |
160/100 |
|
2am |
170/110 |
|
4am |
170/110 |
|
6am |
190/110 |
S- Sob resolved , pedal edema resolved, no difficulty sleeping, mild body aches present.
O- Patient is conscious, coherent, cooperative
Pallor present
No signs of icterus, cyanosis, lymphadenopathy, pedal edema
BP- 170/100 mmhg
PR- 80 bpm
RR- 20 cpm
CVS- S1,S2 heard, parasternal heave grade 2,
diffuse apex beat (right ventricular apex)
no palpable P2
Raised jvp, no thrills, no tender points.
Respiratory system:- BAE + , Nvbs heard
P/A :- soft, non tender, no orgamomegaly
CNS - NAD
Absolute eosinophil count:- 360 cells/mm3
Blood urea - 118 mg/dl.
Serum creatinine:- 5.9 mg/dl
A:- HFpEF with CKD ? Primary glomerular disease with Anemia of chronic disease.
H/o HTN since 2 years.
P:-
1)TAB. CILNIDIPINE 10 MG PO / BD
2)TAB. ARKAMINE 0.1mg TID
3)TAB ULTRACET 1/2 TAB SOS
4)BP MONITORING HOURLY
5)T. DYTOR 5mg PO/OD
6)FLUID AND SALT RESTRICTION.
|
TIME |
BP(mmhg) |
|
8pm(24/2/22) |
160/100(T.Cilnidipine 10mg) |
|
9pm |
150/110 |
|
10pm |
160/100(T.Arkamine 0.1mg) |
|
11pm |
150/100 |
|
12am(25/2/22) |
140/90 |
|
2am |
160/90 |
|
4am |
160/100 |
|
6am |
170/120 |
|
8am |
170/100 (T.Cilnidipine 10mg, T. Dytor 5mg at 8:45am) |
S- Sob increased , pedal edema resolved, slightly difficulty sleeping
O- Patient is conscious, coherent, cooperative
Pallor present
No signs of icterus, cyanosis, lymphadenopathy, pedal edema
BP- 170/100 mmhg
PR- 80 bpm
RR- 20 cpm
CVS- S1,S2 heard, parasternal heave grade 2,
diffuse apex beat (right ventricular apex)
no palpable P2
Raised jvp, no thrills, no tender points.
Respiratory system:- BAE + , Nvbs heard
P/A :- soft, non tender, no orgamomegaly
CNS - NAD
T3 0.8
T4 12.05
TSH 6.04
Blood urea - 122mg/dl
Hb- 7.6 g/dl
A:- HFpEF with CKD ? Primary glomerular disease with Anemia of chronic disease.
H/o HTN since 2 years.
P:-
1)TAB. CILNIDIPINE 10 MG PO / BD
2)TAB. ARKAMINE 0.1mg TID
3)TAB ULTRACET 1/2 TAB SOS
4)BP MONITORING HOURLY
5)T. DYTOR 5mg PO/OD
6)FLUID AND SALT RESTRICTION.
7)Tab. MetXL 12.5 mg BD
8)Inj. THIAMINE I amp in 100 ml NS/ IV/OD
|
TIME |
BP(mmhg) |
|
8am |
170/100( cilnidipine 10mg ARKAMINE 0.1mg, Dytor 5mg) |
|
9am |
160/100 |
|
10am |
160/90 |
|
11am |
160/100 |
|
12pm |
150/100 |
|
1pm |
150/100(ARKAMINE 0.1mg, met xl 12.5mg) |
|
2pm |
160/100 |
|
4pm |
150/100 |
|
5pm |
150/100 |
|
6pm |
160/100 |
|
8pm |
160/110( cilnidipine 10mg) |
|
10pm |
150/100( ARKAMINE 0.1mg, met xl 12.5mg) |
|
12am |
150/100 |
|
2am |
160/100 |
|
4am |
160/100 |
|
6am |
140/100 |
|
8am |
140/100( tab. CILNIDIPINE 10mg, ARKAMINE 0.1mg, Dytor 5 mg) |
Ward
37/M
S- Sob improved , pedal edema resolved, difficulty sleeping, complains of weakness
O- Patient is conscious, coherent, cooperative
Pallor present
No signs of icterus, cyanosis, lymphadenopathy, pedal edema
BP- 150/100 mmhg
PR- 88 bpm
RR- 20 cpm
CVS- S1,S2 heard, parasternal heave grade 2,
diffuse apex beat (right ventricular apex)
no palpable P2
Raised jvp, no thrills, no tender points.
Respiratory system:- BAE + , Nvbs heard
P/A :- soft, non tender, no orgamomegaly
CNS - NAD
Blood UREA- 131 mg/dl
Serum creatinine:- 6 mg/dl
Electrolytes:- Na- 138 k+ 4.0 Cl 104
Serum uric acid - 9.2 mg%
A:- HFpEF with CKD ? Primary glomerular disease with Anemia of chronic disease.
H/o HTN since 2 years.
P:-
1)TAB. CILNIDIPINE 10 MG PO / BD
2)TAB. ARKAMINE 0.1mg TID
3)TAB ULTRACET 1/2 TAB SOS
4)BP MONITORING HOURLY
5)T. DYTOR 5mg PO/OD
6)FLUID AND SALT RESTRICTION.
7)Tab. MetXL 12.5 mg BD
8)Inj. THIAMINE I amp in 100 ml NS/ IV/O
Saidulu abg
28/2/22
37/M
S- pedal edema present, pitting type till mid leg,
Sob resolved, no generalized weakness
O- Patient is conscious, coherent, cooperative
Pallor present
No signs of icterus, cyanosis, lymphadenopathy, pedal edema
BP- 140/100 mmhg
PR- 76 bpm
RR- 20 cpm
CVS- S1,S2 heard, parasternal heave grade 2,
diffuse apex beat (right ventricular apex)
no palpable P2
Raised jvp, no thrills, no tender points.
Respiratory system:- BAE + , Nvbs heard
P/A :- soft, non tender, no orgamomegaly
CNS - NAD
A:- HFpEF with CKD ? Primary glomerular disease with Anemia of chronic disease.
H/o HTN since 2 years.
P:-
1)TAB. CILNIDIPINE 10 MG PO / BD
2)TAB. ARKAMINE 0.1mg TID
3)TAB ULTRACET 1/2 TAB SOS
4)BP MONITORING HOURLY
5)T. DYTOR 5mg PO/OD
6)FLUID AND SALT RESTRICTION.
7)Tab. MetXL 12.5 mg BD
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