Hypertensive emergency with K/C/O DCMP,CRF

 Introduction:A 40year old female patient who is labourer came to OPD with 

CHIEF COMPLAINTS of : 

1.Cough ass c̅ sputum

2.Fever (on and off) 

3.SOB @REST

4.Pedal odema
 
Since 15 days 

HOPI:

The patient was asymptomatic 8 months back She  had sudden onset of Cough-which is productive and in scanty amounts,not associated with fever,sob,
she wnt to local Rmp and got treated . after receiving IV fluids for 1 week near rmp ,patient developed sob (grade 2-3) and also cough didnt subside ,she also developed bilateral pedal edema 
so pt visited NIMS hospital ,where they told she was having ANEMIA and fluid around the heart ( ? pericardial effusion /?DCMP)
she received medication for few days after which her cough and edema subsided

After 10 days ,pt was again dyspneic and developed generalised edema for which she again visited NIMS hospital . On evaluation pt found to have nephrotic range proteinuria which necessitated the cause for renal biopsy although the biopsy showed merely any change
h/o covid 19 in sep 2020 and  was in home isolation 
she was diagnosed to have glomerulonephritis in dec 2020  ( c3 -c4 --normal ) ( albumin 2=, rbc-20-25,spot pcr2.98)
USG was done on 10/4/2021 which showed,-- CMD lost , B/L GRADE 2/3 RPD 
Pt was using medication since theen for dcmp and renal failure and is on regular followup to NIMS hospital till april 2021
Later pt went to home town and lost followup 
there is history of weight loss since 6 months 
loss of appetite
nausea +

15 days back pt again developed generalised edema ,sob,cough for which she visited local hosp in miryalaguda 
she was admitted there and investigations done which showed Hb:4gm% ad platelet count 25k
she received inj.erythropoeitin and 5 units prbc  was transfused 

PT was stabilised and was reffered here in view of renal failure .she was denovo detected to have hypothyroidism 10 days ago .she got discharged on 19/7/2021
 her latest CBP values (23/07/2021) --> hb- 7.3 g/dl ,TLC:9,270 cells per mm3 ,platelets: 1.38 lakhs 

PERSONAL HISTORY:

diet mixed 
decreased appetite 
B/B : regular 
sleep: normal


TREATMENT HISTORY:-

patient was using medications for renal failure 

GENERAL EXAMINATION:-

The patient is conscious coherent cooperative

Pallor is present



No cyanosis

No icterus

No clubbing

Edema is present below upto knee(pitting type)

No lymphadenopathy

No malnutrition
goitre +

SYSTEMIC EXAMINATION:-


CVS:-

No thrills present

Cardiac sounds: S1,S2 (+)

Cardiac murmurs absent

JVP Increased

Parasternal haeve (+)
epigastric pulsations +
no palpable heart sounds or thrills 


RESPIRATORY SYSTEM:-

Dyspnoea is present

No wheeze

Position of trachea: central

Breathe sounds: vesicular

Adventitious sounds absent


CNS:-

Patient is conscious

Speech is normal

Reflexes are normal



PROVISIONAL DIAGNOSIS:-
Hypertensive emergency with grade 1 hypertensive retinopathy 
With k/c/o DCMP WITH CKD
ANEMIA UNDER EVALUATION 
WITH HYPOTHYROIDISM 


INVESTIGATIONS:-

RFT: 
      UREA: 110
      CREATININE: 8.5
      URIC ACID : 9.1
      CA+2 : 8.9
      PO4: 7.4
      NA+: 133
      K+: 4
     CL-: 97

LFT:

   TB: 1.5 
   DB:0.34
   AST: 32
   ALT : 34
    ALP: 189
   TP : 6.0
    ACB: 3.1
    A/G RATIO : 1.06

SERUM LDH:  237

D-DIMER: 1600ng/ml



URINARY ELECTROLYTES [NA,K]




URINE PROTEIN /CREATININE RATIO




COMPLETE URINE EXAMINATION




SERUM IRON




ANTI HCV ANTIBODIES-RAPID




HEMOGRAM




HIV1/2 RAPID TEST




HBS AG - RAPID



APTT




PROTHROMBIN TIME




RETICULOCYTE COUNT






ECG





USG: 







TREATMENT:-


24/07/2021


VITALS:-

PR: 125bpm/min

Bp Lt arm:160/100mmHg

Temp: afebrile

SPO2: 88%

RX:

INJ LASIX [40mg IV/ BD /IF ]

T. TELMA [40mmhg]

T LIVOGEN [150 mg /OD]

T MET -XC [25mg /OD]

FLUID RESTRICTION [< 1 L/DAY]

SALT RESTRICTION [ < 2 mg /day]

BP/PR/TEMP/RR- 4th hourly

STRICT I/O - charting

25/07/2021


VITALS:-

PR: 91bpm/min

Bp Lt arm:120/90mmHg

Temp: afebrile

SPO2: 88%

RR: 25/MIN


CVS:-

        PARASTERNAL haeve (+)

        Cardiac sounds: S1,S2 (+)

        APEX BEAT : 5th intercostal space 

        JVP Increased

         Parasternal haeve (+)

RESPIRATORY SYSTEM:-

         nvbs (+)

         bae(+)

p\a :soft

CNS:-NAD

RX:

FLUID RESTRICTION[< 1 L/DAY]

SALT RESTRICTION [<2.4gm /day]

INJ LASIX[40mg IV BD]

T.MET XL [25 mg /bd]

T. LIVOGEN [150 mg/od]

BP/PR/TEMP/RR- 4th hourly

I/O-charting
 
T ECOSPRIRIN [BD]

T SPIRANOLACTONE [50 mg/od]

T NICARDIA RETARD [20 mg /TID]

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