76 years old MALE WITH CARDIOGENIC SHOCK, ATRIAL FIBRILLATION, HFREF (17%) PRE RENAL AKI ON CKD, RIGHR UPPER LOAB FIBROSIS (post TB sequelae)

76 years old MALE patient came with complaints of DIFFICULTY IN BREATHING since 1 month

HOPI : 
Patient was apparently alright before 1 month then he devoloped DIFFICULTY IN BREATHING insidious in onset and gradually progressive from grade -1 to grade -2 then to grade -4 (mmrc) 
No h/o cough
No h/o chest pain, chest tightness 
No h/o sweating / giddiness
No h/o vomitings /diarrhoea
No h/o bleeding manifestations

PAST HISTORY :
K/C/O PULMONARY TUBERCULOSIS took medication for 6 months 2years ago and also took the same medication for 6 months 4 years ago.
Not a K/C/O HTN /DM / ASTHAMA /EPILEPSY/CAD

PERSONAL HISTORY :
Diet - mixed,  Appetite -decreased
Bladder - Normal
Bowel - constipation
ADDICTIONS : Regular Alcoholic took 1 bottle of toddy/day since 40years , stopped 2 months ago
Smokes 4-6 chuttas /day since 40 years, stopped 2  months ago. 

FAMILY HISTORY :
No history of similar complaints in the family. 
No history of DM/HTN/TB/ASTHAMA/EPILEPSY/CAD

DRUG HISTORY :
No known drug allergy

ON EXAMINATION :
No pallor
No icterus
No cynosis
No clubbing
No lymphedenopathy
No pedal edema
JVP :Not elevated
APEX BEAT : left 5th ics, mid clavicular line
APEX PULSE DEFICIT : 10
Temp - 98.6
Pulse - 110 bpm
Bp - 100/60 mm of hg
RR - 24 cpm
Spo2 : 96 %at Room air

CVS : s1, s2 heard , no murmurs
RS : B/l air entry present  , decreased air entry in right ICA, IAA, no other added sounds 
PA : soft, nontender, no organo megaly 
CNS : Normal

PROVISIONAL DIAGNOSIS :
Heart failure with Reduced ejection fraction secondary to CAD, 
Severe LV Dysfunction, 
Right upper loab fibrosis (post TB) 

INVSTIGATIONS :
HEMOGRAM : Hb - 12.7 , pcv -37.8, Tlc- 11,000, Rbc - 4.44 , Plt - 2,00,000
UREA - 124 , Sr. CREATININE - 2.5
Sr. SODIUM -145 , Sr. POTASSIUM - 4.5 , Sr. CLORIDE - 103 , PT-16, INR - 1.11
Total Bilurubin - 2.9 , Direct Bilurubin - 1.57 , SGPT - 200 , SGOT - 62 , Total Proteins - 5.7 , Albumin - 3.5
CUE : Pus cells - 2 to 4

ECG on 03/03/2024 , 4.10 pm👇

TREATMENT : on 03 /03/2024
Fluid restriction less than 1.5ltr/day , 
Salt restriction less than 2gm/day , 
inj. Dobutamine 0.5mcg/kg/min iv infusion, 
inj. Heparin 500 IU sc. Qid, 
inj. Lasix 40mg iv bd, 
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Metoprolol 25 mg PO. BD
Head end elevation
Strict I/o charting
Vitals monitoring

ECG on 04/03/24 ,  11.58 am👇

2.D ECHO ON 04/03//2024 
RCA - Hypokinetic
LAD - Akinetic
Severe MR, Moderate TR with PAH, EF -20%, Severe LV dysfunction, grade1 Diastolic dysfunction, Dilated LA, LV, RA, IVC

ON EXAMINATION at 8am 04/03/2023
Temp - 97.6
Pulse = 86bpm
BP =100/60 mm of hg
RR =30cpm
SPO2 =96% at RA
I/O, =700/950
JVP - Not elevated
APEX PULSE DEFICIT =6

INVESTGATIONS  : 
UREA -135 , CREATININE - 2.5 , Sr. SODIUM - 147 ,  Sr. Potassium - 4.0 , Sr. CLORIDE - 102

TREATMENT ON 04/03/2024
Fluid restriction less than 1.5ltr/day , 
Salt restriction less than 2gm/day , 
inj. Dobutamine 0.5mcg/kg/min iv infusion, 
inj. Heparin 500 IU sc. Qid, 
inj. Lasix 40mg iv bd, 
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Metoprolol 25 mg PO. BD
Head end elevation
Strict I/o charting
Vitals monitoring

ECG ON 04/03/2024 at 8.50pm👇

ECG ON 05/03/2024 at 7.20am👇
ON EXAMINATION on 05/03/2024 8am
Temp - 98.3
Pulse = 88bpm
BP =100/70 mm of hg
RR =20cpm
SPO2 =98% at RA
I/O, =600/1300
GRBS - 113

INVESTIGATIONS :
Sr. URIC ACID - 11.2
Sr. MAGNISIUM - 2.3
TROPONIN. I - 62.6

DIAGNOSIS : Cardiogenic shock 2ndary to ACSNSTEMI at Evolving, HFREF (EF-20%) 
Pre Renal AKI on CKD, 
Rt. Upper loab fibrosis (post TB) 


TREATMENT ON 05/03/2024 , 8am
Fluid restriction less than 1.5ltr/day , 
Salt restriction less than 2gm/day , 
inj. Dobutamine 0.5mcg/kg/min iv infusion, 
inj. Heparin 500 IU sc. Qid, 
inj. Lasix 40mg iv bd, 
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Met. XL  12.5 mg PO. BD
Tab. Sildenafil 25mg PO. OD
Intermittent CPAP
Head end elevation
Strict I/o charting
Vitals monitoring

ECG ON 05/03/2024 at 9.15am 👇
ECG ON 05/03/2024 7.05pm 👇


ECG ON 06/03/2024 at 7.30am👇
 

X. Ray on 06/03/2024 

ON EXAMINATION on 06/03/2024 8am
Temp - 98.3
Pulse = 88bpm
BP =100/70 mm of hg
RR =20cpm
SPO2 =98% at RA
I/O, =1220/2100

INVESTGATIONS  : 
UREA -132 , CREATININE - 2.2 
 , Sr. SODIUM - 147 ,  Sr. Potassium - 3.8 , Sr. CLORIDE - 102

DIAGNOSIS : Cardiogenic shock 2ndary to ACSNSTEMI at Evolving,LCX, RCA territory), HFREF (EF-20%) 
Pre Renal AKI on CKD, 
Rt. Upper loab fibrosis (post TB) 

TREATMENT ON 06/03/2024 8am
Fluid restriction less than 1.5ltr/day , 
Salt restriction less than 2gm/day , 
ivf. NS @ 30ml /hr
inj. Dobutamine 0.5mcg/kg/min iv infusion, 
inj. Noradrenalin iv. (0.16mg/ml) 4ml/hr
inj. Heparin 500 IU sc. Qid, 
inj. Lasix 40mg iv bd, 
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Met. XL  12.5 mg PO. BD
Tab. Febuxostat 40mg PO. OD
Intermittent CPAP
Head end elevation
Strict I/o charting
Vitals monitoring

ECG ON 06/03/2024 at 5.30pm


ECG ON 06/03/2024 at 10.30pm


ECG ON 07/03/2024 at 7.30am


X. Ray on 07/03/24

DIAGNOSIS : Cardiogenic shock 2ndary to ACSNSTEMI at Evolving,LCX, RCA territory),with ATRIAL FIBRILLATION HFREF (EF-20%) , Cardio Renal syndrome, 
Pre Renal AKI on CKD, 
Rt. Upper loab fibrosis (post TB) 

ON EXAMINATION at 8am 07/03/2023
Temp - 98.4
Pulse = 110 bpm irregular
BP =90/60 mm of hg
RR =30cpm
SPO2 =96% at RA
I/O, = 1520/900
JVP - Not elevated
APEX PULSE DEFICIT =14
CVS -s1s2 present, irregular heart beat
RS - BAE present
PA- soft, non tender, no organo megaly

INVESTGATIONS  : 
UREA -123 , CREATININE - 1.8
 , Sr. SODIUM - 143 ,  Sr. Potassium - 3.0 , Sr. CLORIDE - 103

TREATMENT ON 07/03/2024 8am
Fluid restriction less than 1.5ltr/day , 
Salt restriction less than 2gm/day , 
ivf. NS @ 30ml /hr
inj. Dobutamine 2amps in 45ml NS @ 3ml /hr(dose adjustment according to MAP to maintain above 60mm of hg) 
inj. Noradrenalin iv. (0.16mg/ml) 2.5ml/hr to maintain MAP above 60mm of hg. 
inj. Heparin 5000 IU sc. Qid, 
inj. Lasix 40mg iv tid, 
Tab. Digoxin 0.25mg po. OD
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Febuxostat 40mg PO. OD
Intermittent CPAP
Head end elevation
Strict I/o charting
Vitals monitoring

ECG ON 07/03/2024 at 7.05pm

ON EXAMINATION on 08/03/2024 8am
Temp - 96.5
Pulse = 110bpm
BP =100/50 mm of hg
RR =24 cpm
SPO2 =98% at RA
I/O = 1170/1050
GRBS - 132

INVESTGATIONS  : 
UREA -115 , CREATININE - 1.6
 , Sr. SODIUM - 140 ,  Sr. Potassium - 3.2 , Sr. CLORIDE - 100

DIAGNOSIS : Cardiogenic shock 2ndary to ACSNSTEMI at Evolving,LCX, RCA territory),with ATRIAL FIBRILLATION HFREF (EF-20%) , Cardio Renal syndrome, 
Pre Renal AKI on CKD, 
Rt. Upper loab fibrosis (post TB) 

TREATMENT ON 08/03/2024 8am
Fluid restriction less than 1.5ltr/day , 
Salt restriction less than 2gm/day , 
ivf. NS @ 30ml /hr
inj. Dobutamine 2amps in 45ml NS @ 1.5 ml /hr(dose adjustment according to MAP to maintain above 60mm of hg) 
inj. Noradrenalin iv. (0.16mg/ml) 2.5ml/hr to maintain MAP above 60mm of hg. 
inj. Heparin 5000 IU sc. Qid, 
inj. Lasix 40mg iv tid, 
Tab. Digoxin 0.25mg po. OD
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Febuxostat 40mg PO. OD
Intermittent CPAP
Head end elevation
Strict I/o charting
Vitals monitoring

ECG ON 09/03/2024 at 5.30am

X. Ray on 09/03/2024 

ON EXAMINATION on 09/03/2024 8am
Temp - 98.5
Pulse = 106 bpm, irregular
BP =100/50 mm of hg
RR =24 cpm
SPO2 =98% at RA
JVP =Not raised
APEX PULSE DEFICIT = 6
CVS - s1s2 present, irregular heart beat
RS - BAE present
PA - soft, non tender, no organo megaly
I/O = 1170/900
GRBS -98

DIAGNOSIS : Cardiogenic shock 2ndary to ACS NSTEMI at Evolving,LCX, RCA territory),with ATRIAL FIBRILLATION HFREF (EF-20%) , Cardio Renal syndrome, 
Pre Renal AKI on CKD, 
Rt. Upper loab fibrosis (post TB) 

TREATMENT ON 09/03/2024 at 8am
Fluid restriction less than 1.5ltr/day , 
Salt restriction less than 2gm/day , 
ivf. NS @ 30ml /hr
(inj. Dobutamine stopped as BP is maintained) 
inj. Heparin 5000 IU sc. Qid, 
inj. Lasix 40mg iv tid, 
Tab. Digoxin 0.25mg po. OD
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Febuxostat 40mg PO. OD
Intermittent CPAP
Head end elevation
Strict I/o charting
Vitals monitoring

ECG ON 10/03/2024 at 7.20am


ON EXAMINATION ON 10/03/2024 at 8am
Temp - 98.5
Pulse = 104 bpm, irregular
BP =90/50 mm of hg
RR =26 cpm
SPO2 =98% at RA
JVP =Not raised
APEX PULSE DEFICIT = 6
CVS - s1s2 present, irregular heart beat
RS - BAE present
PA - soft, non tender, no organo megaly
I/O = 1050 /700
GRBS -98

DIAGNOSIS : Cardiogenic shock 2ndary to ACS (NSTEMI at Evolving ,LCX, RCA territory RESOLVED),with ATRIAL FIBRILLATION HFREF (EF-20%) , Cardio Renal syndrome type -1
Pre Renal AKI on CKDCKD (Resolving) 
Rt. Upper loab fibrosis (post TB) 

TREATMENT ON 10/03/2024 at 8am
Oral fluid intake, 
Salt restriction less than 2gm/day , 
ivf. NS @ 30ml /hr
inj. Heparin 5000 IU sc. Qid, 
inj. Lasix 40mg iv tid, 
Tab. Digoxin 0.25mg po. OD
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Febuxostat 40mg PO. OD
Tab. Digoxin 0.25 0
Tab. Met. Xl 12.5 mg . OD(if  SBP more than 100) 
Intermittent CPAP
Head end elevation
Strict I/o charting
Vitals monitoring 

ECG ON 11/03/2024 at 6.40am
ON EXAMINATION ON 11/03/2024 at 8am
Temp - 98.7
Pulse = 90 bpm, irregular
BP =110/60  mm of hg
RR =24 cpm
SPO2 =98% at RA
JVP =Not raised
APEX PULSE DEFICIT = 6
CVS - s1s2 present, irregular heart beat
RS - BAE present
PA - soft, non tender, no organo megaly
I/O = 1050 /700
GRBS -

DIAGNOSIS : Cardiogenic shock 2ndary to ACS (NSTEMI at Evolved in  LCX, RCA territory RESOLVED),with ATRIAL FIBRILLATION (resolving)  
HFREF (EF-17%) , 
Cardio Renal syndrome type -1
Pre Renal AKI on CKDCKD (Resolving) 
Rt. Upper loab fibrosis (post TB) 

TREATMENT ON 10/03/2024 at 8am
Plenty of oral fluids
Salt restriction less than 2gm/day , 
ivf. NS @ 30ml /hr
inj. Heparin 5000 IU sc. Qid, 
inj. Lasix 40mg iv tid, 
Tab. Digoxin 0.25mg po. OD
Tab. Ecosprin 75 + clopidogrel 75 + atorvastatin 20mg PO. HS
Tab. Febuxostat 40mg PO. OD
Tab. Digoxin 0.25 0
Tab. Met. Xl 12.5 mg . OD(if  SBP more than 100) 
Intermittent CPAP
Head end elevation
Strict I/o charting
Vitals monitoring 












 

















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