HYPERTENSIVE EMERGENCY WITH GRADE 1 HYPERTENSIVE RETINOPATHY
HYPERTENSIVE EMERGENCY WITH GRADE 1 HYPERTENSIVE RETINOPATHY
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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 1HYPERTENSIVE 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
2D ECHO REPORT:
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 ratoi : 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 NIKARDIA RETARD [20 mg /TID]
ON 26/07/2021
O/E
PT IS C/C/C
AFEBRILE PR: 106BPM
BP:150/110mmHg of right upper limb
150/100 mmHg of left upper limb
170/100 mmHg of right lower limb
160/110 mmHg of left lower limb
CVS:S1 S2 HEARD
R/S : NVBS +, DECREASED BREATH SOUNDS IN BILATERAL ISA
P/A : SOFT
RX:
FLUID RESTRICTION < 1LIT PER DAY
SALT RESTRICTION <2.4 G/DAY
INJ LASIX 40 MG IV /BD
T.NICARDIA 20 MG PO/TID
T.MET XL 50 MG PO/BD
T.ECOSPIRIN -AV (75/10 )PO/HS
SYP. ASCORYL -D PO/BD 5 ML
BP/TEMP/PR/RR CHARTING 4TH HRLY
I/O CHARTING
BP CHARTING
TAB.THYRONORM 25 MICROGRAM PO/OD (BBF)
ON 27/07/2021:
SOB DECREASED,SLEEP ADEQUATE,STOOLS PASSED
ON EXAMINATION, PT IS C/C/C , AFEBRILE
PR: 72 BPM
BP: 150/90 MM HG
RR: 21
SPO2 96 % ON ROOM AIR
GRBS: 124 MG /DL
CVS:S1 S2 HEARD
CNS: NAD
R/S : NVBS+, DECREASED BREATH SOUNDS IN B/L ISA
P/A: SOFT
I/O : 900/600
RX:
FLUID RESTRICTION < 2LIT PER DAY
SALT RESTRICTION <2.4 G/DAY
T.NICARDIA 20 MG PO/TID
T.MET XL 50 MG PO/BD
T.ECOSPIRIN -AV (75/10 )PO/HS
SYP. ASCORYL -D PO/BD 5 ML
BP/TEMP/PR/RR CHARTING 4TH HRLY
I/O CHARTING
BP CHARTING
TAB.THYRONORM 25 MICROGRAM PO/OD
T.DYTOR 5 MG PO/OD
ON 28/07/2021:
NO FEVER SPILKES,DRY COUGH +,SOB DECREASED SLEEP AND APPETITE NORMAL
O/E ; PT IS C/C/C ,AFEBRILE,
PR: 92BPM
BP: 140/90 MMHG IN UPPER LIMB
150/100 MMHG IN LOWER LIMB
SPO2 : 97% ON ROOM AIR
GRBS: 115MG/DL
CVS: S1 S2 HEARD
CNS: NAD
RS: NVBS +
P/A SOFT
RX:
FLUID RESTRICTION < 2LIT PER DAY
SALT RESTRICTION <2.4 G/DAY
T.NICARDIA 20 MG PO/TID
T.MET XL 50 MG PO/BD
T.ECOSPIRIN -AV (75/10 )PO/HS
SYP. ASCORYL -D PO/BD 5 ML
BP/TEMP/PR/RR CHARTING 4TH HRLY
I/O CHARTING
TAB.THYRONORM 25 MICROGRAM PO/OD
T.DYTOR 5 MG PO/OD
DISCHARGE SUMMARY:
Name of Treating Faculty
DR.ARJUNKUMAR
Diagnosis
Hypertensive emergency with grade 1 hypertensive retinopathyWith k/c/o DCMP WITH CKD ANEMIA UNDER EVALUATIONWITH HYPOTHYROIDISM
Case History and Clinical Findings
A 40year old female patient who is labourer came to OPD with
CHIEF COMPLAINTS of :
1.Cough ass c¯ sputum
2.Fever (on and off)
3.SOB @REST
4.Pedal odemaSince 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 edemaso 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 RPDPt was using medication since then 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 monthsloss 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)
Nolymphadenopathy
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
Investigation
RFT ,LFT,HEMOGRAM,CUE,ABG,
USG ABDOMEN AND PELVIS
CXR
ECG
2D ECHO
SERUM LDH :237
D DIMER 1600ng/ml
URINARY ELECTROLYTES
Na: 192
k:12.4
cl:249
serum iron 81
serology
aptt 32 sec
PT 17
INR 1.2
RETICULOCYTE COUNT 1%
XRAY SKULL
Treatment Given(Enter only Generic Name)
ON 24/07/2021
RX:
INJ LASIX [40mg IV/ BD /IF ]
T. TELMA [40mmhg]
T LIVOGEN [150 mg /OD]
TMET -XC [25mg /OD]
FLUID RESTRICTION [< 1 L/DAY]
SALT RESTRICTION [ <2 mg/day]
BP/PR/TEMP/RR- 4th hourly
STRICT I/O CHARTING
ON 25/07/2021
FLUID RESTRICTION[< 1L/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]
TSPIRANOLACTONE [50 mg/od]
T NICARDIA RETARD [20 mg /TID]
ON 27/07/2021
FLUID RESTRICTION[< 1 L/DAY]
SALT RESTRICTION [<2.4gm /day]
TAB NICARDIA 20MG PO/TID
T.METXL [25 mg /bd]
SYP ASCORIL D PO/BD 5 ML
BP/PR/TEMP/RR- 4th hourly
I/O-charting
T ECOSPRIRIN [BD]
T THYRNORM 25 MICROGRAM PO/OD
T.DYTOR 5MG PO/OD
ON 28/07/2021
FLUID RESTRICTION[< 1 L/DAY]
SALT RESTRICTION [<2.4gm /day]
TAB NICARDIA 20MG PO/TID
T.MET XL [50mg /bd]
BP/PR/TEMP/RR- 4th hourly
I/O-charting
T ECOSPRIRIN [BD]
TTHYRNORM 25 MICROGRAM PO/OD
ON 29/07/2021
FLUID RESTRICTION[< 1 L/DAY]
SALTRESTRICTION [<2.4gm /day]
T.MET XL [25 mg /bd]
BP/PR/TEMP/RR- 4th hourly
I/O-charting
TECOSPRIRIN [BD]
T THYRNORM 25 MICROGRAM PO/OD
SYP GRILLINCTUS BM /PO/TID
TAB NICARDIA 20MG PO/TID
TAB LASIX 40MG PO/BD
Advice at Discharge
FLUID RESTRICTION <2L /DAY
SALT RESTRICTION <2-4 G/DAY
TAB NICARDIA 20MG PO/TID
T MET-XL 50 MG PO/BD
T ECOSPIRIN AV [75/10]PO/HS
T THYRONORM 25MICROGRAM PO/OD
SYP GRILLINCTUS BM PO /TID
TAB LASIX 40MG PO/BD
Lama notes:
PT ATTENDER HAS BEEN EXPLAINED ABOUT THE PT CONDITION REGARDING ANEMIA,RENAL FAILURE ,HEART FAILURE AND NEED FOR DIALYSIS AND BLOOD TRANSFUSION IN THEIR OWN LANGUAGE .INSPITE OF EXPLAINING ATTENDERWANTS TO TAKE PT HOME DUE TO PERSONAL REASONS .SO PT HAS BEEN SENT ON LAMA.DOCTORS,STAFF AND MANAGEMENT ARE NOT RESPONSIBLE FOR ANY FURTHER EVENTS
