GM case history 3

 60 yr old female, presented to the casualty with cheif complaint of pedal edema from one month and facial puffiness for the past 15days.

HISTORY OF PRESENT ILLNESS:

 S0B since a day 

Bilateral pedal edema since 1 month

 Facial puffiness and Abdominal distension for the past 15 days.

HISTORY OF PAST ILLENESS:

She is a resident of Miryalaguda, having 4 children. Patient used to work as ayamma in govt Hospital she stopped working 5 years ago due to jaundice and abdominal distension.

Patient  is chronic alchoholic and non smoker

History of one episode of seizure 8 years ago. No other seizure episode till date.

5 years ago patient had History of abdominal distension and jaundice- she visited our hospital and got admitted. Records are not available.

She was on irregular medication since then. 2 years ago patient was again admitted in our hospital in the view of SOB and pedal edema- she was diagnosed to have Right Heart failure and moderate PAH and CLD and AKI. 

She was diagnosed to have diabetes 2 years ago and is on GLIMI - M1 since then. 

No history of Hypertension, TB, Asthma, Coronary antery disease, CVA.

 Patient still continue to drink daily. stopped one week ago.

No history of chest pain and decreased urine output.

PERSONAL HISTORY

Appetite - Normal

Bowels - Regular

Habits - Alcohol on regular basis 

FAMILY HISTORY 

No significant family history 

PHYSICAL EXAMINATION

No Pallor 

Icterus is present

Oedema of feet is present

Pulse Rate - 130 /min 

Respiration Rate -  35/min 

BP - not recordable 

SPO2 - 78 - 82 % at room air 

JVP - Raised 

SYSTEMATIC EXAMINATION 

CVS:

Cardiac sounds - S1 S2 soft

RESPIRATORY SYSTEM:

Position of Trachea - Central 

Respiratory sounds - decreased bilateral air entry 

CNS:Normal

PROVISIONAL DIAGNOSIS 

Acute pulmonary heart disease

Pulmonary arterial hypertension

Moderate pericardial effusion

Chronic liver disease and thrombocytopenia

Renovascular disease

Diabetes mellitus

Chronic alcoholism

REPORTS 

ECG

     

BLOOD UREA 

Blood Urea - 71 mg/dl

GLYCATED HAEMOGLOBIN - 6.9%

LIVER FUNCTION TEST (LFT)

Total Bilirubin - 9.01mg/dl

Direct Bilirubin - 4.10 mg/dl

SGOT(AST) - 131 IU/L

SGPT(ALT) - 43 IU/L 

Alkaline Phosphate  - 491 IU/L 

Total Proteins - 8.8 gm/dl

Albumin - 3.6 gm/dl

A/G Ratio - 0.71 

BLOOD SUGAR TEST- RANDOM 

RBS - 203mg/dl

ABG

PH - 7.32 

PCO2 - 21.3 mmHg

PO2 - 61.3 mmHg 

HCO3 - 10.8 mmol/L

BEB -  -13.5 mmol/L

TCO2 - 22.9 VOL

O2 Sat - 81.9 %

O2 Count - 11.8 vol%

SERUM ELECTROLYTES (Na , K , C l )

SODIUM - 125 mEq/L

POTASSIUM - 3.9 mEq/L

CHLORIDE - 95 mEq/L

TROPONIN-I   - NEGATIVE 

SERUM CREATININE 

Serum creatinine  - 0.8 mg/dl

TREATEMENT

1. Injection Lasix 40mg  IV STAT

2.  Injection Nor-Adrenaline ( 2amp in 50ml NS )

@ 10ml/hr

3. Injection  Dobutamine @ 3ml / hr 

4. Injection STREPTOKINASE 2.5 lakh IU/ 

     IV infusion over 1hr (8ml/hr)  ---> f/b

 Injection STREPTOKINASE                                       1 lakh IU (3ml/hr) per hour × 24 hrs

5. Injection Heparin 5000 IU IV STAT

6. Injection Lasix infusion @ 2ml/hr

7. Injection  HAI S/C acc.to GRBS

  8am   2pm    8pm

8. syp- lactulose 15ml  | PO | BD

9. Injection  ceftriaxone 1g | IV| BD

10. T. ART | PO | OD 

11. T Udiliv 300mg | PO | BD