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70M HTN DM CAD





 


A 70-year-old man, born and raised in Gundrapally within a low socioeconomic environment, recalls a pleasant childhood despite lacking formal education. Among four siblings, three have passed away. At the age of 12, he assumed responsibility for tending to approximately 50 cattle, including sheep, goats, buffaloes, and cows. By 25, he transitioned into farming, cultivating 50 acres of land under the supervision of a wealthy landowner, cultivating a variety of crops such as oranges, wheat, and various grains. His marriage at 25 was arranged by his brother and father to a non-relative. He adopted smoking at 25 as a means to remain alert and energetic, while alcohol consumption became a customary practice in their culture, used for socializing or to induce sleep when exhausted or during village disputes. He has three sons engaged in construction work and a daughter married to a farmer who passed away due to alcohol-related issues. His daughter has three children, while each of his sons has started their own families. 


Twenty years ago, he suffered a slip and fall resulting in a fractured tibia, requiring a three-month period of bed rest and herbal treatment, thereafter relying on a walking stick and discontinuing physical labor. Subsequently, he has remained at home, gradually accumulating visceral fat. A decade ago, he experienced sudden and severe chest pain, seeking treatment at Yashoda Hospital in Hyderabad, where he received immediate relief from medication followed by PTCA and stent placement. He has since remained symptom-free. Three years ago, he was diagnosed with hypertension during a hospital visit for fever, initially treated with a 2-rupee tablet, later switched to a 5-rupee tablet, and currently managed with Tab Telma 40mg. Two years ago, he sought medical attention for dizziness and was diagnosed with diabetes, subsequently managed with oral hypoglycemic agents.


Chief complains

Complaining of shortness of breath persisting for one year and swelling in both lower limbs for the past month. 


History of presenting illness

Patient was reportedly asymptomatic a year ago but subsequently developed shortness of breath, starting gradually at Grade I NYHA and progressing to Grade III NYHA, without associated chest pain or sweating. Additionally, the patient reports experiencing abdominal distension, poor urinary stream, nocturia, and hesitancy, but no urgency. The patient also has a cough with scanty, whitish sputum that is non-blood stained and non-foul smelling. Furthermore, there is pedal edema of the pitting type extending up to the knees, along with facial puffiness.


Daily routine

Twenty years ago, his daily routine involved waking up multiple times during the night— at 12 am, 3 am, and 5 am— to switch on the motor for watering the fields. Upon waking, he would clean the cattle area before heading out to the fields for farming activities such as ploughing and harvesting, depending on the season. During breaks, he would rest under a tree to rejuvenate himself. Lunch, typically consisting of rice and curry, was consumed around 12 pm, followed by more work in the fields before returning home. Evenings were dedicated to bhajans and storytelling sessions, often centered around the Bhagavadgita. Dinner would be had at home before retiring for bed around 10 pm. He explained that in those days, time was gauged by observing the stars; they could identify specific stars and use their position to estimate the time, a practice they continue to follow.


During our conversation about his past routines, I discovered that his village had limited knowledge of allopathic medicine and relied heavily on herbal remedies. Leaves of plants such as paithala Bhairavi were used for urinary issues, while sugandha and Satya were employed for nerve-related ailments. He expressed regret over his current inability to venture out due to his mobility issues, as he used to visit the Sreesailam forest to gather leaves for his health.


In contrast, his present daily routine involves waking up around 5 am but spends most of the day idle at home, smoking beedis and socializing with friends. He returns home for lunch, takes a nap, and repeats the same pattern in the evening.


Vitals

Temp-98.6F

PR-80bpm

RR-22cpm

BP-110/80mmhg

CVS:S1S2 Heard, No murmurs

RS: BAE Present, NVBS heard

PA: Soft NT

CNS: NFND






GRBS CHARTING

4PM- 130 MG/DL

7PM- 123 MG/DL

10PM- 180 MG/DL

25/4/24:

2AM- 134 MG/DL

7AM- 106 MG/DL

10AM- 123 MG/DL

1PM- 86 MG/DL

3PM- 104 MG/DL

7PM- 120 MG/DL

10PM- 127 MG/DL

26/4/24:

2AM- 120 MG/DL

7AM- 116 MG/DL

10AM- 202 MG/DL

1PM- 86 MG/DL

3PM- 202 MG/DL

7PM- 140 MG/DL

10PM- 90 MG/DL

27/4/24:

2AM- 97 MG/DL

7AM- 110 MG/DL

10AM- 142 MG/DL

1PM- 120 MG/DL

3PM- 136 MG/DL

7PM- 129 MG/DL

10PM- 145 MG/DL

28/4/24:

2AM- 162 MG/DL

7AM- 112 MG/DL


Investigation HAEMOGRAM: 23/4/24

 HB- 7.8GM/DL

TLC- 6100 CELLS/CUMM

N/L/E/M/B- 50/36/10/04/00 PCV- 22.6 VOL%

MCV- 100.4 FL

MCH- 34.7 PG

MCHC- 34.5 %

RBC COUNT- 2.20 MILLIONS/CUMM 

PLT- 1.50 LAKHS/CUMM

 

HAEMOGRAM: 26/4/24 

HB- 9 GM/DL

TLC- 7000 CELLS/CUMM

N/L/E/M/B- 56/25/9/10/00 PCV- 27.3 VOL%

MCV- 97.5 FL

MCH- 32.0 PG

MCHC- 32.8 %

RBC COUNT- 2.80 MILLIONS/CUMM 

PLT- 1.62 LAKHS/CUMM

 

RFT 23-04-2024 04:13:PM

UREA 35 mg/dl 42-12 mg/dl

CREATININE 1.2 mg/dl 1.3-0.9 mg/dl

URIC ACID 6.7 mmol/L 7.2-3.5 mmol/L

CALCIUM 9.6 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.6 mg/dl 4.5-2.5 mg/dl

SODIUM 140 mmol/L 145-136 mmol/L

POTASSIUM 4.8 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 102 mmol/L 98-107 mmol/L

 

 

RFT 26-04-2024 04:13:PM

UREA 81 mg/dl 42-12 mg/dl

CREATININE 5.2 mg/dl 1.3-0.9 mg/dl

URIC ACID 10.5 mmol/L 7.2-3.5 mmol/L

CALCIUM 10 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.8 mg/dl 4.5-2.5 mg/dl

SODIUM 140 mmol/L 145-136 mmol/L

POTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 104 mmol/L 98-107 mmol/L


 

 

 

RFT 27-04-2024

UREA 81 mg/dl 42-12 mg/dl

CREATININE 4.6 mg/dl 1.3-0.9 mg/dl

URIC ACID 9.0 mmol/L 7.2-3.5 mmol/L

CALCIUM 9.8 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.7 mg/dl 4.5-2.5 mg/dl

SODIUM 140 mmol/L 145-136 mmol/L

POTASSIUM 4.2 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 105 mmol/L 98-107 mmol/L

 

 

RFT 28-04-2024 04:13:PM

UREA 79 mg/dl 42-12 mg/dl

CREATININE 3.6 mg/dl 1.3-0.9 mg/dl

URIC ACID 10.1 mmol/L 7.2-3.5 mmol/L

CALCIUM 9.3 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.6 mg/dl 4.5-2.5 mg/dl

SODIUM 139 mmol/L 145-136 mmol/L

POTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 104 mmol/L 98-107 mmol/L

 

 

LIVER FUNCTION TEST (LFT) 23-04-2024

Total Bilurubin 1.29 mg/dl 1-0 mg/dl

Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 20 IU/L 35-0 IU/L

SGPT(ALT) 19 IU/L 45-0 IU/L

ALKALINE PHOSPHATASE 157 IU/L 119-56 IU/L

TOTAL PROTEINS 7.5 gm/dl 8.3-6.4 gm/dl

ALBUMIN 4.0 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.16



COMPLETE URINE EXAMINATION (CUE) 23-04-2024 04:29:PM

COLOUR Pale yellow 

APPEARANCE Clear

SP.GRAVITY 1.010 

ALBUMIN + 

SUGAR Nil

BILE SALTS Nil 

BILE PIGMENTS Nil 

PUS CELLS 2-3

EPITHELIAL CELLS 2-3 

RED BLOOD CELLS Nil 

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent 

OTHERS Nil

 

SEROLOGY- NEGATIVE 

BGT- O POSITIVE 

HBA1C- 6.2%

RBS- 109MG/DL 

FBS- 99MG/DL 

PLBS- 131MG/DL

FERRITIN- 291 NG/ML 

RETICULOCYTE COUNT- 0.8 %



Treatment Given

INJ HAI SC/TID 4U-4U-4U

INJ LASIX 20MG IV/BD 8AM, 4PM 

TAB TELMA 40 MG PO/OD

GRBS 7TH PROFILE




Age/Gender: 70 Years/Male



Discharge Type: Relieved


Admission Date: 23/04/2024 02:28 PM



Name of Treating Faculty DR. RAKESH BISWAS (HOD) DR. MANASA (ySR)


Diagnosis


HEART FAILURE WITH PRESERVED EJECTION FRACTION (60%) CHRONIC KIDNEY DISEASE


K/C/O CAD SINCE 6 YEARS K/C/O HTN SINCE 6 YEARS K/C/O DM II SINCE 6 YEARS


Case History and Clinical Findings


C/O SOB SINCE 1 YEAR


C/O SWELLING OF BILATERAL LOWER LIMBS SINCE 1 MONTH HOPI:


PT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK, THEN HE DEVELOPED SOB OF INSIDIOUS ONSET INITIALLY GRADE I NYHA, GRADUALLY PROGRESSIVE TO GRADE III NYHA, NOT A/W CHEST PAIN, SWEATING.


H/O ABDOMINAL DISTENSION


H/O POOR STREAM OF URINE, NOCTURIA H/O HECITENCY


NO H/O URGENCY


H/O COUGH WITH SPUTUM, SCANTY, WHITISH IN COLOUR, NOT BLOOD STAINED, NON FOUL SMELLING


H/O PEDAL EDEMA, PITTING TYPE, EXTENDING UPTO KNEES H/O FACIAL PUFFINESS


PAST HISTORY:





K/C/O HTN SINCE 6 YEARS ON TAB AMLOKIND AT 5/50 K/C/O CAD SINCE 6 YEARS ON TAB CLOPITAB


K/C/O DM SINCE 5 YEARS ON TAB METFORMIN 500MG N/K/C/O CVA, SEIZURES, TB, THYROID DISORDERS. ON EXAMINATION:


PT IS CONCIOUS, COHERENT AND COOPERATIVE PALLOR- PRESENT


NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA. TEMP- AFEBRILE


BP- 110/80MMHG PR- 80BPM


RR- 22CPM SPO2- 98%


CVS- S1 S2 HEARD, NO MURMURS


RS- BAE +, NVBS +, B/L DIFFUSE RHOCHI FINE CREPTS +, RT SAA, MA P/A- SOFT, NON TENDER



COURSE IN THE HOSPITAL:


PT WAS ADMITTED IN THE VIEW OF B/L PEDAL EDEMA SINCE 1 MONTH AND SON SINCE 1 YEAR AND STARTED TREATMENT WITH NEBULIZATIONS, INSULIN AND WITH LOOP DIURETICS, CCB'S, NODOSIS, SHELCAL CT, OROFER XT (AS HIS HB WAS 7.8) , VITAMIN C AND MAINTAINED BLOOD SUGAR VALUES IN NORMAL RANGE. RFT ALSO SHOWED GRADUAL IMPROVED FUNCTIONING OF THE KIDNEY. I/O CHARTING WAS MAINTAINED ALONG WITH IV FLUIDS. HB WAS GRADUALLY INCREASED TO 9MG/DL. PT WAS WELL MAINTAINED AND DISCHARGED IN HAEMODYNAMICALLY STABLE CONDITION.


Investigation HAEMOGRAM: 23/4/24 HB- 7.8GM/DL


TLC- 6100 CELLS/CUMM


N/L/E/M/B- 50/36/10/04/00 PCV- 22.6 VOL%


MCV- 100.4 FL


MCH- 34.7 PG


MCHC- 34.5 %





RBC COUNT- 2.20 MILLIONS/CUMM PLT- 1.50 LAKHS/CUMM



HAEMOGRAM: 26/4/24 HB- 9 GM/DL


TLC- 7000 CELLS/CUMM


N/L/E/M/B- 56/25/9/10/00 PCV- 27.3 VOL%


MCV- 97.5 FL


MCH- 32.0 PG


MCHC- 32.8 %


RBC COUNT- 2.80 MILLIONS/CUMM PLT- 1.62 LAKHS/CUMM



RFT 23-04-2024 04:13:PM


UREA 35 mg/dl 42-12 mg/dl


CREATININE 1.2 mg/dl 1.3-0.9 mg/dl


URIC ACID 6.7 mmol/L 7.2-3.5 mmol/L


CALCIUM 9.6 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 3.6 mg/dl 4.5-2.5 mg/dl


SODIUM 140 mmol/L 145-136 mmol/L


POTASSIUM 4.8 mmol/L. 5.1-3.5 mmol/L.


CHLORIDE 102 mmol/L 98-107 mmol/L




RFT 26-04-2024 04:13:PM


UREA 81 mg/dl 42-12 mg/dl


CREATININE 5.2 mg/dl 1.3-0.9 mg/dl


URIC ACID 10.5 mmol/L 7.2-3.5 mmol/L


CALCIUM 10 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 3.8 mg/dl 4.5-2.5 mg/dl


SODIUM 140 mmol/L 145-136 mmol/L


POTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.


CHLORIDE 104 mmol/L 98-107 mmol/L







RFT 27-04-2024


UREA 81 mg/dl 42-12 mg/dl


CREATININE 4.6 mg/dl 1.3-0.9 mg/dl


URIC ACID 9.0 mmol/L 7.2-3.5 mmol/L


CALCIUM 9.8 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 3.7 mg/dl 4.5-2.5 mg/dl


SODIUM 140 mmol/L 145-136 mmol/L


POTASSIUM 4.2 mmol/L. 5.1-3.5 mmol/L.


CHLORIDE 105 mmol/L 98-107 mmol/L




RFT 28-04-2024 04:13:PM


UREA 79 mg/dl 42-12 mg/dl


CREATININE 3.6 mg/dl 1.3-0.9 mg/dl


URIC ACID 10.1 mmol/L 7.2-3.5 mmol/L


CALCIUM 9.3 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 3.6 mg/dl 4.5-2.5 mg/dl


SODIUM 139 mmol/L 145-136 mmol/L


POTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.


CHLORIDE 104 mmol/L 98-107 mmol/L




LIVER FUNCTION TEST (LFT) 23-04-2024


Total Bilurubin 1.29 mg/dl 1-0 mg/dl


Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl


SGOT(AST) 20 IU/L 35-0 IU/L


SGPT(ALT) 19 IU/L 45-0 IU/L


ALKALINE PHOSPHATASE 157 IU/L 119-56 IU/L


TOTAL PROTEINS 7.5 gm/dl 8.3-6.4 gm/dl


ALBUMIN 4.0 gm/dl 4.6-3.2 gm/dl


A/G RATIO 1.16


COMPLETE URINE EXAMINATION (CUE) 23-04-2024 04:29:PM


COLOUR Pale yellow APPEARANCE Clear


REACTION Acidic





SP.GRAVITY 1.010 ALBUMIN + SUGAR Nil


BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3


EPITHELIAL CELLS 2-3 RED BLOOD CELLS Nil CRYSTALS Nil


CASTS Nil


AMORPHOUS DEPOSITS Absent OTHERS Nil



SEROLOGY- NEGATIVE BGT- O POSITIVE HBA1C- 6.2%


RBS- 109MG/DL FBS- 99MG/DL PLBS- 131MG/DL


FERRITIN- 291 NG/ML RETICULOCYTE COUNT- 0.8 %



USG ON 23/4/24:


RIGHT GRADE I RPD CHANGES WITH RIGHT SIMPLE RENAL CORTICAL CYST LEFT GRADE I-II RPD CHANGES



2D ECHO ON 24/4/24:


EF- 62%


MILD MR+/AR+, TRIVIAL TR+, NO PAH NO RWMA, MILD CONCENTRIC LVH+ GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION NO PE CLOTS







GRBS CHARTING:


24/4/24:


4PM- 130 MG/DL


7PM- 123 MG/DL


10PM- 180 MG/DL


25/4/24:


2AM- 134 MG/DL


7AM- 106 MG/DL


10AM- 123 MG/DL


1PM- 86 MG/DL


3PM- 104 MG/DL


7PM- 120 MG/DL


10PM- 127 MG/DL


26/4/24:


2AM- 120 MG/DL


7AM- 116 MG/DL


10AM- 202 MG/DL


1PM- 86 MG/DL


3PM- 202 MG/DL


7PM- 140 MG/DL


10PM- 90 MG/DL


27/4/24:


2AM- 97 MG/DL


7AM- 110 MG/DL


10AM- 142 MG/DL


1PM- 120 MG/DL


3PM- 136 MG/DL


7PM- 129 MG/DL


10PM- 145 MG/DL


28/4/24:


2AM- 162 MG/DL


7AM- 112 MG/DL





Treatment Given(Enter only Generic Name)


INJ HAI SC/TID ACC TO GRBS INJ LASIX 20MG IV/BD 8AM, 4PM TAB TELMA 40 MG PO/OD


GRBS 7TH PROFILE


Advice at Discharge


TAB TELMA 40MG PO/OD X TO CONTINUE


TAB LASIX 20MG PO/BD 8AM AND 4PM X 1 MONTH


TAB NODOSIS 500MG PO/BD 8AM AND 8PM X TO CONTINUE TAB SHELCAL CT PO/OD 2PM X 15 DAYS


TAB OROFER XT 8PM PO/OD X 1 MONTH TAB VITAMIN C PO/OD X 1 MONTH



SIGNATURE OF PATIENT /ATTENDER




SIGNATURE OF PG/INTERNEE




SIGNATURE OF ADMINISTRATOR




SIGNATURE OF FACULTY




Discharge Date


Date:26/4/24





Ward:MMW Unit: II


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