48 Year old male with chief complaints of shortness of breath

*NOTE- This is an ongoing case, this E-log will be updated as and when we find new information.

CHIEF COMPLAINT - 48-Year-old male presented to the OPD with chief complaints of Shortness of Breath from the past 1 week which has gotten severe in the last 4 days

HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 

2 years back, on routine examinations, he was found to have a  deranged RFT, a diagnosis of Chronic renal failure was made and conservative, symptomatic treatment for the same was done. 

7 months back, the patient had chest pain, for which he visited a hospital where he was said to be having heart failure, an angiogram was done after which he was normal. 

2 months back, the patient had Shortness of breath for which he went to a hospital and was given symptomatic treatment. 
He was asymptomatic for those 2 months 

One week back, he again had shortness of breath grade - II (from the past 1 week ) which progressed to grade III-IV in the past 4- 5 days, orthopnoea and bendopnoea were present. 

HISTORY OF PAST ILLNESS 

Known case of
  • Diabetes Mellitus from the past 7 years 
  • Hypertension from the past 7 years 
  • Chronic renal failure was diagnosed 2 years back 
  • Heart Failure 7 months back, angiogram was done 
No History of - 
  • CAD,ASTHMA,TB

DRUG HISTORY 

 Till the day of admission, the patient was using Tab. Shelcal

PERSONAL HISTORY 
  • Married
  • Occupation - construction worker 
  • Appetite - Normal 
  • Diet-Non vegetarian 
  • Bowel Movements- Irregular 
  • Micturation - Normal 
  • The patient is a known alcoholic for the past 25 years, and he stopped consuming alcohol 3 years back. 

FAMILY HISTORY 
  • No relevant family history 

GENERAL EXAMINATION 
  • The patient is conscious, coherent.
  • Edema of feet present 
  • Absence of Cyanosis, Pallor, Icterus, Lymphadenopathy, clubbing.

VITALS 
  1. Temperature - Afebrile 
  2. Respiratory  rate - 18 beats per minute 
  3. Blood Pressure - 100/80 mmHg
  4. SPO2- 98 percent 

CVS EXAMINATION 
  • S1, S2 heard 
  • No Murmurs or thrills

RESPIRATORY SYSTEM EXAMINATION 
  • Dyspnoea - present 
  • Wheeze - Absent 

PER ABDOMEN 
  • No tenderness, palpable mass, Free fluid 
  • Non-palpebral spleen and liver 
  • Bowel sounds heard 

CNS EXAMINATION 
  • The patient is conscious 
  • He has normal speech 
  • No neck stiffness, kerning sign 
  • Cranial nerves - Normal 
  • Motor and Sensory system normal 
  • Glasgow scale - 15/15
  • Fingernose incoordination, Knee heel Incoordination - Absent 
  • Normal gait

INVESTIGATIONS -

1.Fasting blood sugar -Elevated 



2.Post Lunch Blood Sugar -Elevated



3.Glycated Haemoglobin- 6.8 percent 


4. Erythrocyte sedimentation rate-Elevated


5.Complete blood Picture- Hb lower than normal 


6.ABG


7.Liver Function Test 


7. Lipid Profile 


8.USG report 


9. Renal Function Test
 (10/7/2021)





(14/7 2021)


10.2 D echo


11.ECG







INVESTIGATIONS - 20th July 2021


1. AFB CULTURE AND SENSITIVITY REPORT -
NEGATIVE



2. PULMONARY FUNCTION TEST - 20th July 2021 

Findings- 
Pre Medication findings 
1. Early small airway obstructions as FEF25-75 % Pred or  PEFR % Pred <70
2.Spirometry within normal limits as (FEV1/FVC) % Pred> 95 and FVC% Pred >80 
Post Medication Findings 
3. Mild restriction as (FEV1/FVC) % Pred >95 and FVC % <80 


PROVISIONAL DIAGNOSIS  - HFrEF secondary to CAD; CRF

DIAGNOSIS -

ACUTE ON CHRONIC LVF
HFrEF SECONDARY TO CAD 
CKD- STAGE 4 
RENOCARDIAC 4 

TREATMENT - DAY 1

1. TAB. BISOPROLOL 5mg OD
2.TAB. NITROHART 20/37.5mg 1/2 T/D
3.TAB NICARDIA XL 30mg OD
4.TAB. GLICIAZIDE 80mg BD
5.TAB. NODOSIS 500 mg TD
6.Cap. BIO-D3 OD
7.Cap. GEMSOLINE OD
8.TAB. ECOSPRIN-AV 150/20mg OD
9.TAB.LASIX 40mg BD
10. SYP. LACTULOSE 15ml

TREATMENT DAY 2
  1. FLUID RESTRICTION <1.5 L /DAY 
  2. SALT RESTRICTION <2 G DAY
  3. TAB BISOPROLOL 5MG OD
  4. TAB NICARDIA XL 30mg OD
  5. TAB. GLICIAZIDE 80mg BD
  6. TAB. NODOSIS 500 mg TD
  7. Cap. BIO-D3 OD
  8. Cap. GEMSOLINE OD
  9. TAB. ECOSPRIN-AV 150/20mg OD
  10. TAB.LASIX 40mg BD
  11.  SYP. LACTULOSE 15ml
TREATMENT DAY 3 - 
  1. FLUID RESTRICTION <1.5 L / DAY 
  2. SALT RESTRICTION <2 G /DAY 
  3. TAB BISOPROLOL 5MG OD 
  4. TAB GLICIAZIDE 80 MG BD
  5. TAB NODOSIS 500 MG TID 
  6. CAP BIO - D3 OD 
  7. CAP GEMSOLINE 
  8. TAB. ECOSPRIN-AV 150/20mg OD
  9. TAB.LASIX 40mg BD
  10. TAB HYDALIZINE 25 MG PO /TID 
  11. SYP CREMMAFIN PLUS 15 ML / TID 

SUMMARY 
-
This is the case of a 48 year old male who presented with chief complaints of shortness of breath , the patient has a history of chronic renal failure  2 years back and heart failure seven months back . The patient has Diabetes mellitus and Hypertension from the past 7 years , on examination we found out that the blood glucose was higher than normal , symptomatic treatment was done for it , renal function test was deranged and atrial flutter / tachycardia , with rapid ventricular response, widespread T wave abnormality  was seen in the ECG 
A provisional diagnosis of Heart Failure with reduced ejection fraction secondary to CAD was made, with CKD . Acid fast bacterial culture  was done , the report was negetive ,as a result the pulmonary function test was done , on the basis of which the following diagnosis was made 
ACUTE ON CHRONIC LVF
HFrEF SECONDARY TO CAD 
CKD- STAGE 4 
RENOCARDIAC 4 


LINKS- 
 Beta-blockers and renin-angiotensin system inhibitors have yielded promising results in patients with HFrEF associated with advanced kidney disease . 

2. Heart failure in patients with chronic kidney disease: a systematic integrative review

Liviu Segall, Ionut Nistor, Adrian Covic, "Heart Failure in Patients with Chronic Kidney Disease: A Systematic Integrative Review", BioMed Research International, vol. 2014, Article ID 937398, 21 pages, 2014. https://doi.org/10.1155/2014/937398
Patient, Problem: Adults with a primary diagnosis of CKD and HF
Intervention: HF treatment was defined as any formal means taken to improve the symptoms of heart failure
Comparison: 1439 Patients were compared, and 23 articles were hand-searched.
Outcomes: Control of fluid overload, use of beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and optimization of dialysis appear to be the most important methods to treat patients with HF in CKD and ESRD patients

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