HFpEF with CKD with HTN
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
60 y/o female came to the casuality with the chief complaints of
1. SOB since the past 8 days
The patient was apparantly asymptomatic 8 days ago. At 2pm she developed an episode of SOB. Orthopnoea + and PND +. It lasted for 2 hours. She was taken to local RMP. SOB resolved on medication. The next day patient was take to a private hospital at Suryapet. There diagnosis of anemia (Hb 3.4, RBC 1.1 million, PCV 10.2, TLC 9500) was made and blood transfusion was adviced which the patient refused.
2 years back, she developed pedal edema (pitting type, upto knee) not a/w facial puffiness, reduced urine output. The patient was taken to nearby doctor and was diagnosed to have renal failure l. Tab DYTOR 5mg and Tab NODOSIS 50mg po/bd for 5 days. She was not followed up further.
K/C/O HTN since 4 years (on Tab AMLONG 5mg po/od)
Not a K/C/O DM, TB, asthma, epilepsy.
The patient is married. Currently unemployed and stays at home. She used to be a farmer.
Now she has reduced appatite
Takes vegetarian diet
Bowels irregular
Micturition normal
No known allergies
No addictions
On Examination
Pt is C/C/C
Thin built and undernourished
Pallor severe
No icterus, cyanosis, lymphadenopathy, clubbing, pedal edema
Dehydrated - mild
Afebrile
PR 86bpm
BP 100/60 mmHg
RR 24 cpm
SpO2 100% at room air
CVS
S1 S2 heard
JVP elevated
RS
Dyspnoea +
Wheeze -
Trachea central
Breath sounds vesicular
P/A
Soft, non-tender, bowel sounds +
CNS
Pt is conscious
Speech normal
No signs of neck stiffness
Cranial nerves, motor and sensory system normal
GCS 15/15
Reflexes R L
1. Biceps 2+ 2+
2. Triceps + +
3. Supinator - -
4. Knee + +
5. Ankle + +
Prov Diagnosis
HFpEF with CKD with HTN
High risk consent taken
Consent for central line insertion taken
Central line insertion
1. Indication - Hemodialysis
2. Site - R IJV
3. Technique - Mod. Seldinger Technique
Post procedure x ray taken
Hemodialysis performed at 1:30 am with 1 unit PRBC transfusion for uremic encephalopathy (elevated blood urea and creatinine).
SOAP NOTES DAY 0
ICU 6TH BED
S
Pt is C/C/C
Has SOB
Pedal edema
O
Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 100/60 mmHg
PR 86 bpm
RR 24 cpm
SpO2 100 at room air
A
HFpEF with CKD with HTN with severe anemia
P
1. Fluid restriction < 1.5 L
2. Salt restriction < 2gm
3. Inj LASIX 40mg iv/od
4. Inj ONDONSETRON 4mg iv/sos
5. Tab NICARDIA 20mg po/od
6. Inj PANTOP 40mg iv/od
7. Tab OROFER XT po/bd
8. Tab NODOSIS 550mg po/bd
9. BP PR RR Temp 4th hrly monitoring
10. I/O charting
11. Tab SHELCAL 500mg po/bd
12. Inj AUGMENTIN 1.2g iv/bd
SOAP NOTES DAY 1
ICU 6TH BED
S
Pt drowsy
Tachypnoeic
GCS E2V3M4
O
Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 150/80 mmHg
PR 115 bpm
RR 20 cpm
I/O 100/200
Stools not passed
GRBS 120mg/dl
A
CKD with Anemia secondary to ? CKD with HFpEF with HTN with ?ARDS
P
1. Head end elevation
2. BIPAP Intermittently 2nd hrly with O2 to maintain sats above 94%
3. Inj LASIX 40mg iv/bd (8am 4pm), if SBP more than 110 mmHg
4. Inj PANTOP 40mg iv/od
5. Inj ZOFER 4mg iv/sos
6. Inj AUGMENTIN 1.2gm iv/bd (D3)
7. Tab NICARDIA 20mg po/bd
8. Tab OROFER XR po/bd
9. Tab NODOSIS 550mg po/bd
19. Tab SHELCAL 500mg po/bd
11. Vitals monitoring 4th hrly
12. I/O charting
SOAP NOTES DAY 2
ICU 6TH BED
S
Pt altered sensorium
Drowsy
SOB +
GCS E2V3M3
Saturation dropping to 75
I/O 200/350
Stools not passed
O
Pallor +
Clubbing -
Icterus +
Pedal edema -
Afebrile
PR 102 BPM
BP 160/90 mmHg
RR 25
GRBS 122mg/dl
CVS S1 S2 +
RS B/L coarse crepts
P/A soft, non-tender
CNS E2V3M3
RFT
Urea 57
Creat 3
UA 2.9
Ca 9.4
P 4.4
Na 140
K 3.7
Cl 96
ABG
pH 7.37
pO2 48.3
pCO2 30.1
HCO3 C 17.2
HCO3 ST 18.8
A
CKD with Anemia secondary to ?CKD with HFpEF with HTN with ?ARDS/?Cardiogenic Pul Edema
P
1. Ryle's tube feed (200ml milk 4th hrly, 100ml water hrly)
2. Head end elevation
3. BIPAP Intermittently 2nd hrly with O2 to maintain sats above 94%
4. Inj LASIX 40mg iv/bd (8am 4pm)
5. Inj PANTOP 40mg iv/od
6. Inj ZOFER 4mg iv/sos
7. Inj AUGMENTIN 1.2gm iv/bd (D3)
8. Tab NICARDIA 20mg po/bd
9. Tab OROFER XR po/bd
10. Tab NODOSIS 550mg po/bd
11. Tab SHELCAL 500mg po/bd
12. Vitals monitoring 4th hrly
13. I/O charting
SOAP NOTES DAY 3
ICU 6TH BED
S
Pt altered sensorium
Drowsy but arousable
SOB +
GCS E3V1M1
Saturation 92 at 16L O2
I/O 1500/900
Stools not passed
O
Pallor +
Clubbing -
Icterus +
Pedal edema -
Pupils pin point, equal on both sides. Non reactive to light
Afebrile
PR 70 BPM
BP 130/70 mmHg
RR 22
GRBS 219 mg/dl
CVS S1 S2 +
RS B/L inspiratory crepts at IAA, IMA, ISA
P/A soft, non-tender
Reflexes
Reflexes R L
1. Biceps + +
2. Triceps - -
3. Supinator - -
4. Knee + +
5. Ankle + +
6. Plantar mute mute
ABG
pH - 7.111
pCO2 - 72.2
pO2 - 11p
HCO3 c - 22.0
HCO3 st - 18.6
Urea
Creat
Na
K
Cl
A
CKD with Anemia secondary to ?CKD with HFpEF with HTN with ?ARDS/? Non-Cardiogenic Pul Edema
P
1. Ryle's tube feed (200ml milk 2nd hrly with protein powder, 100ml water hrly)
2. Head end elevation
3. O2 inhalation to maintain O2 sat at above 94%
4. BIPAP Intermittently 2nd hrly
5. Inj LASIX 40mg iv/bd (8am 4pm)
6. Inj PANTOP 40mg iv/od
7. Inj ZOFER 4mg iv/sos
8. Inj AUGMENTIN 1.2gm iv/bd (D3)
9. Tab AMLONG 5mg po/od
10. Tab NODOSIS 550mg po/tid
11. Nebulisation with BUDECORT 12th hrly, IPRAVENT 6th hrly
12. Vitals monitoring 4th hrly
13. I/O charting
