Sharing an outlier to our often made diagnosis of a metabolic syn diabetic phenotype here as a valuable challenge to the ease of diagnosing through phenotype hypothesis.
This man doesn't have diabetes or hypertension after regular monitoring since last few days here in ICU.
67M with severe cor pulmonale due to chronic bronchitis
He said was smoking since 3 years of age after his mother died when he was 2 and his father made him work in his tobacco firm rolling tobacco leaves, which his 3 year old self loved consuming! He gave up smoking since last 5 years and was admitted with anasarca and shortness of breath.
EMR SUMMARY
Age/Gender : 67 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 17/01/2025 07:20 PM
Name of Treating Faculty
@PPM3, @PPM4 and @PPM5
Diagnosis
RIGHT HEART FAILURE(COR-PULMONALE) OBSTRUCTIVE SLEEP APNEA
RELATIVE POLYCYTEMIA(HCT-50) PRE RENAL AZOTEMIA CELLULITIS OF LEFT LOWER LIMB
RIGHT SIDED CHRONIC HYDROCELE
Case History and Clinical Findings
Chief COMPLAINTS-ABDOMINAL DISTENSION SINCE 2 MONTHS SOB SINCE 20 DAYS
HOPI-
PATIENT WAS APPARANTLY ASYMPTOMATIC 2 MONTHS AGO AND THEN Developed Abdominal DISTENSION SINCE 2 MONTHS, ASSOCIATED WITH SHORTNESS OF BREATH SINCE 20DAYS GRADE III-IV MMRS, INSIDIOUS ONSET AND GRADUALLY PROGRESSIVE ,PND -, ORTHOPNOEA +
H/O YELLOWISH DISCOLORATION OF EYES SINCE 2 MONTHS
H/O PEDAL EDEMA SINCE 2 MONTHS, MODERATE,PITTING TYPE, EXTENDING UPTO KNEE NO H/O FEVER, SOLD SOUGH, ALLERGIES, CHEST APIN, PALPITATIONS, SWEATING, ABDOMINAL PAIN,
NOH/O NAUSEA, VOMITINGS, LOOSE STOOLS, BURING MICTURITION, DECREASE IN URINE OUTPUT
PAST HISTORY-
N/K/C/O DM, HTN, TB, EPILEPSY, ASTHMA, CVA,CAD
PERSONAL HISTORY DIET-MIXED
SLEEP-ADEQUATE APPETITE- LOST
BOWEL MOVEMENTS-- CONSTIPATION MICTURITION- NORMAL
ADDICTIONS-ALCOHOL SINCE 50 YEARS OCCASSIONALLY 90ML LAST INTAKE WAS 10 DAYS BACK
1CHUTTA PACK / 3DAY AND STOPPED 5 YEARS BACK
GENERAL EXAMINATION PT IS C/C/C TEMP.AFEBRILE
PR 116 BPM BP 90/70MMHG RR 23/MIN
SPO2 92% ON 4 L O2
GRBS 109 MG/DL
SYSTEMIC EXAMINATION:
CVS: S1 S2 HEARD , NO MURMURS RS: BAE +, NVBS
P/A: SOFT, NT, NO ORAGANOMEGALY CNS-NFND
REFERED TO GENERAL SURGERY I/V/O ULCER OVER LEFT LOWER LIMB RX1.CONTINUE TREATMENT ADVICED AS PER PHYSICIAN 2.TAB.CHYMEROL FORTE PO/TID
3. TAB DOLO 650 MG PO/SOS
4. MGSO4 GLYCERIN DRESSING
5. B/L LOWER LIMB CREPE BANDAGE AF
67YEAR OLD MALE PRESENTED WITH CHEIF COMPLAINTS ABDOMINAL DISTENSION SINCE
2 MONTHS, PEDAL EDEMA SINCE 2 MONTHSSOB SINCE 20 DAYS AND K/C/O CHRONIC SMOKER AND OCCASSIONAL ALCOHOLIC. NECESSORY INVESTIGATIONS WERE SENT AND BED SIDE 2DECHO WAS DONE SHOWING DILATED RIGHT ATRIUM AND DILATED RIGHT VENTRICLE WITH NON COLLAPSING IVC AND WAS DIAGONSED AS COR PULMONALE
PATIENT WAS STARTED ON LASIX, THIAMINE AND ANTIBIOTICS. PATIENT HAD SWELLING ON LEFT LOWER LIMB AND SURGERY REFERRAL WAS TAKEN AND DIAGNOSED AS LEFT LOWER LIMB CELLULITIS AND RIGHT SIDED CHRONIC HYDROCELE FOR WHICH SUPPORTIVE MANAGEMENT WAS GIVEN. 2DECHO WAS DONE SHOWED EF 61% WITH GOOD LV SYSTOLIC FUNCTION, DILATED RA, RV WITH DILATED IV. ASCITIC TAP WAS DONE WHICH SHOWED HIGH SAAG AND HIGH PROTEIN AND SUPPORTIVE MANAGEMENT WAS GIVEN. PATIENT WAS IMPROVED CLINICALLY AND DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION.
Investigation
Anti HCV Antibodies - RAPID 17-01-2025 07:59:PM Non Reactive HBsAg-RAPID 17-01-2025 07:59:PM Negative
SERUM ELECTROLYTES (Na, K, C l) 18-01-2025 12:44:AM SODIUM 133 mmol/L 145-136
mmol/LPOTASSIUM 4.5 mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107 mmol/L
BLOOD UREA 18-01-2025 07:37:AM 79 mg/dl 50-17 mg/dl SERUM CREATININE 18-01-2025
07:37:AM 1.2 mg/dl 1.3-0.8 mg/dl SERUM ALBUMIN ON 18/1/25- 3.7 g/dl
ABG 18-01-2025 07:37:AMPH 7.36PCO2 25.4PO2 60.7HCO3 14.3St.HCO3 17.4BEB -8.8BEecf - 10.0TCO2 27.1O2 Sat 89.0O2 Count 21.7
RFT 20-01-2025 12:08:AM UREA 55 mg/dl 50-17 mg/dl CREATININE 1.3 mg/dl 1.3-0.8 mg/ dl URICACID 9.3 mmol/L 7.2-3.5 mmol/LCALCIUM 9.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.8 mg/dl 4.5-
2.5 mg/dl SODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 3.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
104 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 20-01-2025 12:08:AM Total Bilurubin 4.20 mg/dl 1-0 mg/dl Direct Bilurubin 1.26 mg/dl 0.2-0.0 mg/dl SGOT(AST) 21 IU/L 35-0 IU/LSGPT(ALT) 14 IU/L 45-0
IU/LALKALINE PHOSPHATASE 228 IU/L 119-56 IU/LTOTAL PROTEINS 5.9 gm/dl 8.3-6.4
gm/dl ALBUMIN 2.9 gm/dl 4.6-3.2 gm/dl A/G RATIO 0.94
RFT 20-01-2025 11:00:PM UREA 55 mg/dl 50-17 mg/dl CREATININE 1.5 mg/dl 1.3-0.8 mg/dl URIC
ACID 8.4 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 3.7 mg/dl 4.5-
2.5 mg/dl SODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
98 mmol/L 98-107 mmol/L
APTT TEST ON 20/1/25- 33 SEC PT TIME/INR ON 20/1/25
Prothrombin Time 17 SECINR 1.2 HS-TROPONIN I ON 20/1/25 TROPONIN-I 27.7 pg/ml
USG DONE ON 17/1/25 IMPRESSION
-ALTERED ECHOTEXTURE OF LIVER
-MILD TO MODERATE ASCITIS HEMOGRAM ON 20/1/25
HAEMOGLOBIN 16.5 gm/dl TOTAL COUNT 12,400 cells/cumm NEUTROPHILS 76 % LYMPHOCYTES 20 % EOSINOPHILS 02 % MONOCYTES 02 % BASOPHILS 00 % PCV 50.2 vol % M C V 81.8 fl M C H 26.9 pg M C H C 32.9 % RDW-CV 17.2 % RDW-SD 51.2 fl RBC COUNT 6.1
millions/cumm PLATELET COUNT 1.5 lakhs/cu.mm SMEARRBC Normocytic normochromic Light Microscopy WBC leukocytosis Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic with leukocytosis
HEMOGRAM ON 21/1/25
HAEMOGLOBIN 16.6 gm/dl TOTAL COUNT 12,300 cells/cumm NEUTROPHILS 78 % LYMPHOCYTES 11 % EOSINOPHILS 01 % MONOCYTES 10 % BASOPHILS 00 % PCV 49.7 vol % M C V 80.7 fl M C H 27.0 pg M C H C 33.5 % RDW-CV 18.0 % RDW-SD 54.3 fl RBC COUNT 6.15
millions/cumm PLATELET COUNT 1.5 lakhs/cu.mm SMEARRBC Normocytic normochromic Light Microscopy WBC leukocytosis Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic blood picture with leukocytosis
HEMOGRAM ON 22/1/25
HAEMOGLOBIN 16.6 gm/dl TOTAL COUNT 11,000 cells/cumm NEUTROPHILS 79 % LYMPHOCYTES 13 %EOSINOPHILS 01 % MONOCYTES 07 % BASOPHILS 00 % PCV 49.6 vol % M C V 80.8 fl M C H 27.0 pg M C H C 33.4 % RDW-CV 18.0 % RDW-SD 54.4 flRBC COUNT 6.14
millions/cumm PLATELET COUNT 1.50 lakhs/cu.mm SMEAR
RBC Normocytic normochromic Light Microscopy WBC With in normal limits Light Microscopy
PLATELETS Adeqaute Light Microscopy
HEMOPARASITES No hemoparasites seen Light Microscopy
IMPRESSION Normocytic normochromic blood picture
LFT ON 22/1/25
Total Bilurubin 3.67 mg/dl Direct Bilurubin 1.55 mg/dl SGOT(AST) 16 IU/L SGPT(ALT) 10 IU/L ALKALINE PHOSPHATASE 206 IU/L TOTAL PROTEINS 6.1 gm/dl ALBUMIN 2.9 gm/dl A/G RATIO 0.89
RFT ON 22/1/25
UREA 58 mg/dl CREATININE 1.3 mg/dl URIC ACID 8.3 mmol/L CALCIUM 9.8 mg/dl
PHOSPHOROUS 2.9 mg/dl SODIUM 133 mmol/L POTASSIUM 3.5 mmol/L. CHLORIDE 97 mmol/L ASCITIC TAP REPORTS-
ASCITIC FLUID PROTEIN SUGAR:
SUGAR 121 mg/dl PROTEIN 2.9 g/dl ASCITIC FLUID AMYLASE
Ascitic Fluid Amylase-17 IU/L ASCITIC FLUID FOR LDH LDH 130 IU/L
SAAG
Serum Albumin 3.3 gm/dl Ascitic Albumin 1.7 gm/dl SAAG 1.6
2D ECHO WAS DONE ON 18/01/25 REPORT:
- 'D' SHAPE LV
- MODERATE TR+ WITH PAH
- TRIVIAL MR+; NO AR; MILD PR+
- SCLEROTIC AV; NO AS/MS; IAS - INTACT
- EF = 61% GOOD LV SYSTOLIC FUNCTION
- GRADE I DIASTOLIC DYSFUNCTION+
- IVC SIZE (1.90CM) DILATED NON COLLAPSING
- DILATED -> RA/RV MPA - SIZE 2.5CM
- MILD PE+; NO LV CLOT
Treatment Given (Enter only Generic Name)
1. SALT RESTRICTION <2 G/DAY
2. O2 SUPPLEMENTATION >SPO2 92%
3. INJ AUGMENTIN 1.2GM IV/TID FOR 5DAYS
4. INJ LASIX IV/BD 40MG---X---20MG
5. INJ CLEXANE 40MG S.C/OD
6. INJ THIAMINE 200MG IV/BD
7. TAB. MET-XL 25MG PO/BD
8. TAB.PCM 40 MG PO/OD
9. TAB.REJUNEX CD3 PO/OD
10. TAB.UDILIV 300MG PO/BD
11. STRICT I/O CHARTING
12. MONITORING VITALS AND INFORM SOS
Advice at Discharge
SALT RESTRICTION <2 G/DAY FLUID RESTRICTION <2L/DAY
HOME O2 / CPAP SUPPLEMENTATION >SPO2 92% TAB DYTOR PLUS 20/50MG PO OD FOR 1 MONTH TAB THIAMINE 100MG PO/BD FOR 1MONTH
TAB. MET-XL 25MG PO/OD TO CONTINUE TAB.PAN-D 40 MG PO/OD FOR 1MONTH TAB.REJUNEX CD3 PO/OD FOR 1MONTH TAB.UDILIV 300MG PO/BD FOR 1MONTH
TAB ECOSPRIN AV 75/10MG PO OD TO CONTINUE TAB.IVABRAD 5MG PO/BD X15DAYS
OINT.T-BACT L/A TID WITH DRESSINGS OVER LEFT LOWER LIMB COMPLETE ALCOCHOL ABSTIENCE
Follow Up
REVIEW TO GM OPD AFTER 2WEEK WITH HEMOGRAM, RFT AND LFT REPORTS.
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date: 22/1/25 Ward: ICU
Unit: V
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