74M CHF HTN DM PROSTATE CA

 

74 male from jalalpuram came with complaints of sob and chest pain since 3 days 

Patient was born and brought up in jalalpuram,lived along with parents and 3 siblings,studies till 9th standard,no health issues in childhood, discontinued education and entered carpenter work at 16 yrs of age.

He got married at age of 21 years and had 3 sons and 1 daughter and lead a relatively healthy life,

Patient remained asymptomatic till 14 years ago then he developed tingling sensation and weakness of limbs intermittently for which he went to local hospital and was diagnosed of having high blood pressures around 200/100 and was started on anti hypertensives,he was continuing medication and his bp was under control and remained asymptomatics until 7 yrs ago,

At that time he had h/o burning micturition along with pain and dribbling of urine ,he went to local hospital for that and was diagnosed of having prostatic carcinoma and resection of tumor was done at that time and also used medication for 2 years,in between he went to warangal as he was unsatisfied with the treatment of doctors there and went to warangal for further treatment as the symptoms like polyuria,burning micturition persisted even after surgery,there he was found to have recurrence of prostatic carcinoma and placed him on medical management,

Since then he was on medication for carcinoma and hypertension,

2 months ago patient developed weakness of limbs for which he went to hospital and found to have high blood sugars and was started on oral hypoglycemics,during that time he had itching over limbs and accidentally ruptured a nodule on his leg and undervent surgical procedure to close that wound

And discharged after 7 days.Since then he was worried about his health and as his financial conditions becoming worse he felt some what tensed and depressed and stopped taking medications for prostatic cancer,

Since 1 month patient noticed that he is having sob and intermittent chest pain while doing sternous work and while lifiting weights,

Sob and chest pain aggrevated since past 3-4 days for which he was brought to casuality by his attenders

No addictions

No significant family history

PHENOTYPE

Mid arm circumference- 30cms

Waist circumference- 82cms

Abdominal circumference- 87cms

Hip circumference-92cms

CHEST X-RAY PA VIEW

ECG

USH

2D ECHO

*DIAGNOSIS*

HEART FAILURE WITH REDUCED EJECTION FRACTION

HTN

DM

Discharge summary;

:74 Years/Male

Admission Date: 10/06/2024 09:29 AM

Diagnosis

1)HEART FAILURE SECONDARY TO CAD/CAD AKINETIC RCA,LCX HYPOKINETIC WITH REDUCED EF (32%)

2)ATRIAL FIBRILLATION

K/C/O HTN SINCE 5 YEARS ; DM2 5 MONTHS

S/PB/ORCHIODECTOMY

CASTRATION RESISTENT PROSTATE CARCINOMA 5 YEARS 

Case History and Clinical Findings

CHIEF COMPLAINTS:

SHORTNESS OF BREATH SINCE 1 WEEKCHEST PAIN SINCE 1 WEEK

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY AASYMPTOMATIC 1 WEEK BACK THEN HE DEVELOPEDDIFFICULTY IN BREATHEING SINCE 1 WEEK ASSOCIATEWD WITH ORTHOPNEA PNDSWEATING GIDDINESS .

PATIENT COMPLAINTS OF CHEST TIGHTNESS CHEST PAINPATIENT HAS NO H/O INVOLUNTARY MOVEMENTS

NO H/O ABDOMINAL PAIN

H/O NOCTURIA 5-6 TIMES AT NIGHTPAST HISTORY:

K/C/O DM SINCE 3 MONTHS

 HTN SINCE 5 YEARS

PERSONAL HISTORY :

DIET - MIEDAPPETITE - NORMALSLEEP - ADEQUATE

BOWEL& BLADDER MOVEMENTS - REGULAR AND NOCTURIAADDICTIONS - NIL

GENERAL PHYSICAL EXAMINATION :

PATIENT IS CONSCIOUS , COHERENT &COOPERATIVE , WELL ORIENTED TO TIME ANDPLACE .

NO PALLOR/ ICTERUS / CYANOSIS / CLUBBING / LYMPHADENOPATHY / OEDEMA.VITALS :

BP ; 140/70MM HGPR : 84 BPM

RR : 20CPMTEMP ; 98FSPO2:94@RA

GEBS- 137 MG/ DL

SYSTEMIC EXAMINATION :

CNS :NFNDREFLEXESB T S K A

R +2 +2 + 1 +2 +1

L +2 +2 +1 +2 +1

CVS :

S1, S2 HEARD , NO MURMURS

RS :

BAE + , NVBS

ADVENTITIOUS SOUNDS : CREPTS PRESENT

P/A :

SOFT , NON TENDER

COURSE IN THE HOSPITAL :

74Y OLD MALE CAME TO CASUALITY WITH C/O SHORTNESS OF BREATH SINCE 1 WEEK

.CHEST PAIN SINCE 1 WEEK .ALL NECESSARY INVESTIGATIONS WERE SENT .PATIENT WASDIAGNOSED TO1)HEART FAILURE SECONDARY TO CAD/CAD AKINETIC ,RCA,LCXHYPOKINETIC WITH REDUCED EF (32%) 2)ARTERIAL FIBRILLATION 3)K/C/O HTN SINCE 5YEARS ; K/C/O DM2 SINCE 5 MONTHS 4)S/P B/L ORCHIODECTOMY SECONDARY TOCASTRATION RESISTENT PROSTATE CARCINOMA 5 YEARS AGO. K/C/O DM SINCE 3MONTHS .PATIENT WAS TREATED CONSERVATIVELY WITHTAB.ECOSPRIN,TAB.DABIGATRAN,TAB.DIGOXIN,TAB.VYMADA,TAB.GLIMI-M1,SYPPOTKLOR,SYP.CREMAFFIN PLUS AND INJ AUGMENTIN AND INJ.METROGYL AND TAB MET-XL AND ACCORDINGLY .PATIENT IS BEING DISCHARGED IN A HEMODYNAMICALLY STABLECONDITION .

Investigation

Name Value Range

Name Value RangePOST LUNCH BLOOD SUGAR 10-06-2024 10:46:AM 138 mg/dl 140-0 mg/dlRFT10-06-202410:46:AMUREA24mg/dl50-17mg/dlCREATININE0.8mg/dl1.3-0.8mg/dlURIC

ACID 2.0 mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.4 mg/dl 4.5-

2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE99 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 10-06-2024 10:46:AMTotal Bilurubin 2.90mg/dl 1-0 mg/dlDirect Bilurubin 0.58 mg/dl 0.2-0.0 mg/dlSGOT(AST) 38 IU/L 35-0 IU/LSGPT(ALT) 35IU/L 45-0 IU/LALKALINE PHOSPHATASE 103 IU/L 119-56 IU/LTOTAL PROTEINS 6.4 gm/dl 8.3-6.4gm/dlALBUMIN 4.1 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.82

COMPLETE URINE EXAMINATION (CUE) 10-06-2024 10:46:AMCOLOUR PaleyellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILESALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUSDEPOSITSAbsentOTHERSNilHBsAg-RAPID10-06-

2024 10:46:AM Negative

Anti HCV Antibodies - RAPID 10-06-2024 10:46:AM Non ReactiveSERUM ELECTROLYTES (Na, K,C l) 11-06-2024 05:21:AMSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.3 mmol/L 5.1-3.5

mmol/LCHLORIDE 98 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 11-06-2024 10:37:PMSODIUM 140 mmol/L 145-136

mmol/LPOTASSIUM 3.0 mmol/L 5.1-3.5 mmol/LCHLORIDE 98 mmol/L 98-107 mmol/LRFT 12-06-

2024 10:46:PMUREA 45 mg/dl 50-17 mg/dlCREATININE 0.9 mg/dl 1.3-0.8 mg/dlURIC ACID 3.9

mmol/L 7.2-3.5 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.0 mg/dl 4.5-2.5

mg/dlSODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 3.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99

mmol/L 98-107 mmol/L

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5L/DAY

SALT RESTRICTION <2.5 GM/DL

INJ.LASIX 100MG IN 50 ML NS @5ML./HR

INJ.LASIX 40MG IV/OD

INJ.HAI S/C TID

TAB.TELMISARTAN 40MG PO/OD

TAB.MET-XL 25MG PO/OD

TAB.ECOSPRIN GOLD (75/75/20) PO/HS

TAB.ABIRATERONE 500MG PO/OD

TAB.VYMADA 50MG PO/OD

SYP CREMAFFIN PLUS 15ML PO/STAT

TAB.WYSOLONE 5MG PO/OD

TAB.DIGOXIN 0.25 MG PO/OD

TAB.DABIGATRAN 110MG PO/BD

TAB.GLIMI -M1 PO/BD

SYP POTKLOR 15ML IN 100 ML WATER PO/TID

ZENFLOX - OZ PO/BD

Advice at Discharge

1.FLUID RESTRICTION <1.5L/DAY2.SALT RESTRICTION <2.5 GM/DL3.TAB . GLIMI M1PO/OD6.TAB.TELMISARTAN 40MG PO/OD7.TAB.MET-XL 25MG PO/OD8.TAB.ECOSPRIN GOLD(75/75/20) PO/HS9.TAB.VYMADA 50MG PO/OD10.SYP CREMAFFIN PLUS 15MLPO/STAT11.TAB.WYSOLONE 5MG PO/OD14.TAB.DIGOXIN 0.25 MGPO/OD15.TAB.DABIGATRAN 110MG PO/BD16.SYP POTKLOR 15ML IN 100 ML WATER PO/TIDX5 DAYS17. TAB ZENFLOX - OZ PO/BD X 5 DAYS