HEART FAILURE WITH REDUCED EJECTION FRACTION SECOUNDARY TO CAD (EF=34%) SEVERE PULMONARY HYPERTENSION LEFT LEG DIABETIC FOOT (AMPUTATED ) ANEMIA OF CHRONIC DISEASE PRE-RENAL ACUTE KIDNEY INJURY (RESOLVING) ON CHRONIC KIDNEY DISEASE HTN SINCE 10 YR DIABETES TYPE II SINCE 3YRS LEFT LEG BELOW KNEWW STMPN DEBRIDMENT + PRIMARY CLOSURE UNDER SPINAL ANESTHESIA 2 PRBC TRANSFUSIONS DONE

 Case History and Clinical Findings

PATIENT IS A KNOWN CASE OF GUILLATINE AMPUTATION CAME FOR CLOSURE OF FLAP

PATIENT WAS ADMITTED TO THE IN GENERAL SURGERY KIMS FOR DIABEYES ULCER OVER THE LEFT 2ND TOE AND GOT THE 2ND TOE AMPUTATED ON DEC 2022 AND ADEQUATE BLOOD SUGARS CONTROLE HAS BEED DONE AND PATIENT WAS DISCHRES PATIENT HAS LOST FOLLOW UP AND FURTHER GOT ADMITTED IN GENERAL SURGERY KIMS SILENCER BURN OVER THE DORSUM OF THE FOOT ON NOVEMBER 2023 DEBRIDMENT DONE AND REFFERED TO THE NEPHROLOGY AND HE ADVISED TO DIALYSIS AND PATIENT AND PATIENT ATTENDERS WERE NOT WILLING HAD LEFT AGAINST MEDICAL ADVICE

HE WENT TO YASHODHA AND UNDERWENT AMPUTATION AND PATIENT FURTHER CAME TO KIMS FOR FOR THER MANAGMENT

AND CAME FOR STUMP CLOSURE ON 4 /1/24 TO GENERAL SURGERY

NO COUGH AND VOMITING , NAUSEA

NO H/O FEVER,COLD AND ALLERGIES.

PAST HISTORY:

K/C/O DM-II SINCE 3 YEAR ON REGULAR MEDICATION (GLYCOMET-M1 PLUS METFORMIN PO/OD)

K/C/O HTN SINCE 10 YR ON TELMA 40 MG

NOT A K/C/O HTN,ASTHMA,TB,EPILEPSY,CVA,CAD.

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:130/70 MM HG

PR:80 BPM

RR:17 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

GENERAL SURGERY TRANSFER DONE ON 17/1/24 I/V/O ANEMIQA WITH CKD WITH DERANGED LFT AND HEART FAILURE

PROVISIONAL DIAGNOSIS 


HEART FAILURE WITH REDUCED EJECTION FRACTION SECOUNDARY TO CAD (EF=34%)

SEVERE PULMONARY HYPERTENSION

LEFT LEG DIABETIC FOOT (AMPUTATED )

ANEMIA OF CHRONIC DISEASE

PRE-RENAL ACUTE KIDNEY INJURY (RESOLVING) ON CHRONIC KIDNEY DISEASE

HTN SINCE 10 YR DIABETES TYPE II SINCE 3YRS

LEFT LEG BELOW KNEWW STMPN DEBRIDMENT + PRIMARY CLOSURE UNDER SPINAL ANESTHESIA

2 PRBC TRANSFUSIONS DONE


Investigation

Name Value Range

Name Value RangePOST LUNCH BLOOD SUGAR 04-01-2024 06:43:PM 179 mg/dl 140-0 mg/dl

RFT 04-01-2024 06:43:PMUREA 74 mg/dl 42-12 mg/dlCREATININE 2.4 mg/dl 1.3-0.9 mg/dlURIC ACID 5.6 mg/dl 7.2-3.5 mg/dlCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.9 mg/dl 4.5-2.5 mg/dlSODIUM 133 mEq/L 145-136 mEq/LPOTASSIUM 5.1 mEq/L 5.1-3.5 mEq/LCHLORIDE 98 mEq/L 98-107 mEq/LLIVER FUNCTION TEST (LFT) 04-01-2024 06:43:PMTotal Bilurubin 0.60 mg/dl 1-0 mg/dlDirect Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 10 IU/L 35-0 IU/LSGPT(ALT) 11 IU/L 45-0 IU/LALKALINE PHOSPHATE 336 IU/L 128-53 IU/LTOTAL PROTEINS 6.3 gm/dl 8.3-6.4 gm/dlALBUMIN 2.3 gm/dl 5.2-3.5 gm/dlA/G RATIO 0.61

COMPLETE BLOOD PICTURE (CBP) 04-01-2024 06:43:PMHAEMOGLOBIN 9.5 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 7700 cells/cumm 10000-4000 cells/cummNEUTROPHILS 71 % 80-40 %LYMPHOCYTES 20 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 08 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 2.65SMEAR Normocytic normochromic anemiaCOMPLETE URINE EXAMINATION (CUE) 04-01-2024 06:43:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 5-6EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

HBsAg-RAPID 04-01-2024 06:43:PM NegativeAnti HCV Antibodies - RAPID 04-01-2024 06:43:PM Non Reactive

BLOOD UREA 07-01-2024 01:27:PM 18 mg/dl 42-12 mg/dlSERUM CREATININE 07-01-2024 01:27:PM 2.0 mg/dl 1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 07-01-2024 01:27:PMSODIUM 136 mEq/L 145-136 mEq/LPOTASSIUM 4.7 mEq/L 5.1-3.5 mEq/LCHLORIDE 102 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.24 mmol/L mmol/LCOMPLETE BLOOD PICTURE (CBP) 07-01-2024 01:27:PMHAEMOGLOBIN 9.2 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 9000 cells/cumm 10000-4000 cells/cummNEUTROPHILS 73 % 80-40 %LYMPHOCYTES 19 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 07 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 2.31SMEAR Normocytic normochromic anemia

ABG 07-01-2024 01:27:PMPH 7.41PCO2 27.9PO2 99.8HCO3 17.3St.HCO3 19.6BEB -5.8BEecf - 6.4TCO2 35.6O2 Sat 96.9O2 Count 14.7COMPLETE BLOOD PICTURE (CBP) 10-01-2024 06:57:AMHAEMOGLOBIN 9.4 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 6700 cells/cumm 10000-4000 cells/cummNEUTROPHILS 74 % 80-40 %LYMPHOCYTES 20 % 40-20 %EOSINOPHILS 02 % 6-1 %MONOCYTES 04 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 1.8SMEAR Normocytic normochromic anemia

COMPLETE BLOOD PICTURE (CBP) 11-01-2024 05:03:PMHAEMOGLOBIN 10.8 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 12500 cells/cumm 10000-4000 cells/cummNEUTROPHILS 95 % 80-40 %LYMPHOCYTES 03 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 01 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 1.54SMEAR Normocytic normochromic Anemia with Neutrophilic LeukocytosisSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-01-2024 06:11:AMSODIUM 135 mEq/L 145-136 mEq/LPOTASSIUM 3.5 mEq/L 5.1-3.5 mEq/LCHLORIDE 105 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.12 mmol/L mmol/L

COMPLETE BLOOD PICTURE (CBP) 14-01-2024 08:55:AMHAEMOGLOBIN 9.0 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 8000 cells/cumm 10000-4000 cells/cummNEUTROPHILS 92 % 80-40 %LYMPHOCYTES 05 % 40-20 %EOSINOPHILS 00 % 6-1 %MONOCYTES 03 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 1.10SMEAR Normocytic normochromic Anemia with Relative Neutrophilia and ThrombocytopeniaBLOOD UREA 14-01-2024 09:19:AM 96 mg/dl 42-12 mg/dl

SERUM CREATININE 14-01-2024 09:19:AM 2.7 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 14-01-2024 09:19:AMSODIUM 136 mEq/L 145-136 mEq/LPOTASSIUM 3.7 mEq/L 5.1-3.5 mEq/LCHLORIDE 105 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.12 mmol/L mmol/L

BLOOD UREA 15-01-2024 04:42:PM 120 mg/dl 42-12 mg/dlSERUM CREATININE 15-01-2024 04:42:PM 2.9 mg/dl 1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 15-01-2024 04:42:PMSODIUM 132 mEq/L 145-136 mEq/LPOTASSIUM 5.5 mEq/L 5.1-3.5 mEq/LCHLORIDE 104 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.06 mmol/L mmol/LSERUM PROTEIN 15-01-2024 04:42:PM 5.5 g/dl . 8.3-6.4 g/dl .

COMPLETE BLOOD PICTURE (CBP) 15-01-2024 04:42:PMHAEMOGLOBIN 9.3 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 12200 cells/cumm 10000-4000 cells/cummNEUTROPHILS 88 % 80-40 %LYMPHOCYTES 08 % 40-20 %EOSINOPHILS 00 % 6-1 %MONOCYTES 04 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 94.000SMEAR Normocytic normochromic Anemia with Neutrophilic loeukocytosis and ThrombocytopeniaCOMPLETE URINE EXAMINATION (CUE) 15- 01-2024 04:42:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 4-6EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

ABG 15-01-2024 10:36:PMPH 7.39PCO2 20.5PO2 90.1HCO3 12.3St.HCO3 15.9BEB -10.8BEecf - 11.7TCO2 25.3O2 Sat 95.8O2 Count 14.7BLOOD UREA 16-01-2024 07:20:AM 108 mg/dl 42-12 mg/dl

SERUM CREATININE 16-01-2024 07:20:AM 2.9 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na,

C l) AND SERUM IONIZED CALCIUM 07-01-2024 01:27:PMSODIUM 136 mEq/L 145-136 mEq/LPOTASSIUM 4.7 mEq/L 5.1-3.5 mEq/LCHLORIDE 102 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.24 mmol/L mmol/LCOMPLETE BLOOD PICTURE (CBP) 07-01-2024 01:27:PMHAEMOGLOBIN 9.2 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 9000 cells/cumm 10000-4000 cells/cummNEUTROPHILS 73 % 80-40 %LYMPHOCYTES 19 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 07 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 2.31SMEAR Normocytic normochromic anemia

ABG 07-01-2024 01:27:PMPH 7.41PCO2 27.9PO2 99.8HCO3 17.3St.HCO3 19.6BEB -5.8BEecf - 6.4TCO2 35.6O2 Sat 96.9O2 Count 14.7COMPLETE BLOOD PICTURE (CBP) 10-01-2024 06:57:AMHAEMOGLOBIN 9.4 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 6700 cells/cumm 10000-4000 cells/cummNEUTROPHILS 74 % 80-40 %LYMPHOCYTES 20 % 40-20 %EOSINOPHILS 02 % 6-1 %MONOCYTES 04 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 1.8SMEAR Normocytic normochromic anemia

COMPLETE BLOOD PICTURE (CBP) 11-01-2024 05:03:PMHAEMOGLOBIN 10.8 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 12500 cells/cumm 10000-4000 cells/cummNEUTROPHILS 95 % 80-40 %LYMPHOCYTES 03 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 01 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 1.54SMEAR Normocytic normochromic Anemia with Neutrophilic LeukocytosisSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-01-2024 06:11:AMSODIUM 135 mEq/L 145-136 mEq/LPOTASSIUM 3.5 mEq/L 5.1-3.5 mEq/LCHLORIDE 105 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.12 mmol/L mmol/L

COMPLETE BLOOD PICTURE (CBP) 14-01-2024 08:55:AMHAEMOGLOBIN 9.0 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 8000 cells/cumm 10000-4000 cells/cummNEUTROPHILS 92 % 80-40 %LYMPHOCYTES 05 % 40-20 %EOSINOPHILS 00 % 6-1 %MONOCYTES 03 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 1.10SMEAR Normocytic normochromic Anemia with Relative Neutrophilia and ThrombocytopeniaBLOOD UREA 14-01-2024 09:19:AM 96 mg/dl 42-12 mg/dl

SERUM CREATININE 14-01-2024 09:19:AM 2.7 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 14-01-2024 09:19:AMSODIUM 136 mEq/L 145-136 mEq/LPOTASSIUM 3.7 mEq/L 5.1-3.5 mEq/LCHLORIDE 105 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.12 mmol/L mmol/L

BLOOD UREA 15-01-2024 04:42:PM 120 mg/dl 42-12 mg/dlSERUM CREATININE 15-01-2024 04:42:PM 2.9 mg/dl 1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 15-01-2024 04:42:PMSODIUM 132 mEq/L 145-136 mEq/LPOTASSIUM 5.5 mEq/L 5.1-3.5 mEq/LCHLORIDE 104 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.06 mmol/L mmol/LSERUM PROTEIN 15-01-2024 04:42:PM 5.5 g/dl . 8.3-6.4 g/dl .

COMPLETE BLOOD PICTURE (CBP) 15-01-2024 04:42:PMHAEMOGLOBIN 9.3 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 12200 cells/cumm 10000-4000 cells/cummNEUTROPHILS 88 % 80-40 %LYMPHOCYTES 08 % 40-20 %EOSINOPHILS 00 % 6-1 %MONOCYTES 04 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET COUNT 94.000SMEAR Normocytic normochromic Anemia with Neutrophilic loeukocytosis and ThrombocytopeniaCOMPLETE URINE EXAMINATION (CUE) 15- 01-2024 04:42:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 4-6EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

ABG 15-01-2024 10:36:PMPH 7.39PCO2 20.5PO2 90.1HCO3 12.3St.HCO3 15.9BEB -10.8BEecf - 11.7TCO2 25.3O2 Sat 95.8O2 Count 14.7BLOOD UREA 16-01-2024 07:20:AM 108 mg/dl 42-12 mg/dl

SERUM CREATININE 16-01-2024 07:20:AM 2.9 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 16-01-2024 07:20:AMSODIUM 135 mEq/L 145-136 mEq/LPOTASSIUM 5.2 mEq/L 5.1-3.5 mEq/LCHLORIDE 104 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.12 mmol/L mmol/L

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 17-01-2024 12:06:AMSODIUM 135 mEq/L 145-136 mEq/LPOTASSIUM 4.2 mEq/L 5.1-3.5 mEq/LCHLORIDE 104 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.15 mmol/L mmol/LBLOOD UREA 17-01-2024 12:06:AM 148 mg/dl 42-12 mg/dl

SERUM CREATININE 17-01-2024 12:06:AM 3.0 mg/dl 1.3-0.9 mg/dlLIVER FUNCTION TEST (LFT) 17-01-2024 12:06:AMTotal Bilurubin 0.97 mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 24 IU/L 35-0 IU/LSGPT(ALT) 27 IU/L 45-0 IU/LALKALINE PHOSPHATE 935 IU/L 128-53 IU/LTOTAL PROTEINS 5.5 gm/dl 8.3-6.4 gm/dlALBUMIN 2.0 gm/dl 5.2-3.5 gm/dlA/G RATIO 0.59

BLOOD UREA 17-01-2024 10:27:PM 166 mg/dl 42-12 mg/dlSERUM CREATININE 17-01-2024 10:27:PM 3.0 mg/dl 1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 17-01-2024 10:27:PMSODIUM 137 mEq/L 145-136 mEq/LPOTASSIUM 3.6 mEq/L 5.1-3.5 mEq/LCHLORIDE 101 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.16 mmol/L mmol/LBLOOD UREA 18-01-2024 11:37:PM 125 mg/dl 42-12 mg/dl

SERUM CREATININE 18-01-2024 11:37:PM 2.6 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 18-01-2024 11:37:PMSODIUM 141 mEq/L 145-136 mEq/LPOTASSIUM 3.9 mEq/L 5.1-3.5 mEq/LCHLORIDE 103 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.17 mmol/L mmol/L

USG CHEST DONE 17/1

LEFT MILD TO MODERATE PLURAL EFFUSION

RIGHT ATELECTASIS WITH AIR BHRONCHOGRAM

2D ECHO DONE ON 16/1

EF 24 PERCENT

RWMA ,LAD AKINETIC , RCA AND LCA HYPOKINESIA , NO AS/MS

SEVERE LV DYSFUNCTIONN CANCENTRIC LVH

DIASTOLIC DYSFUNCTION

2DECHO 18/01/24 - EF=34%

MODERATE TR WITH PAH RVSP=50MHG

MODERATE MR ; MILD AR/PR

RWMA PRESENT LAD AKINETIC ; RCA WITH LCX HYPOKINESIA

SEVERE LV DYSFUNCTION

IVC SIZE 1.06 CMS COLLAPSING

MINIMAL PE

18/01/2024 PUS FROM WOUND SITE CULTURE - E.COLI ISOLATED

SENSITIVE TO MEROPENEM AND PIPTAZ.

Treatment Given(Enter only Generic Name)

INJ DOBUTAMINE INFUSION 1ML /HR

INJ LASIX 100MG @ 10MG/HR INFUSION WAS GIVEN FOR 2DAYS

INJ.MEROPENEM 500MG IV BD FOR 7DAYS

INJ.METROGEL 500MG IV TID 7DAYS

INJ.CIPROFLOXACIN 5OOMG IV OD FOR 5DAYS

INJ.EPO 4000 IV /SC 4MG IV/TID

CAP BIO D3 PO ONCE A WEEK

INJ.PAN 40MG IV OD

INJ.HAI SC TID 200MG IV 8TH HRLY

TAB.NODOSIS 500MG PO/TID

TAB SHELCAL PO/OD

TAB CHYMEROL FORTE PO/TID

TAB OROFER XT PO/OD

TAB ATORVASTATIN 20MG PO/HS

TAB SILDENAFIL 20 MG PO/ TID

NEB. DUOLIN AND BUDICOTRT

Advice at Discharge

TAB LASIX 20MG PO/BD FOR 1 WEEK 8AM 4PM

TAB.FEROPENEM 300MG PO BD FOR 1 WEEK 8AM 8PM

TAB.NODOSIS 500MG PO/TID FOR 2 WEEKS 8AM 1PM 8PM

TAB SHELCAL PO/OD FOR 2 WEEKS 2PM

TAB CHYMEROL FORTE PO/TID FOR 1 WEEK 8AM 1PM 8PM

TAB OROFER XT PO/OD FOR 2 WEEKS 2PM

TAB ATORVASTATIN 20MG PO/HS 9PM TO CONTINUE

TAB SILDENAFIL 20 MG PO/ TID FOR 1 WEEK 8AM 1PM 8PM

REGULAR DRESSINGS

Follow Up

FOLLOW UP IN GENERAL SURGERY OPD AND

REVIEW TO GENERAL MEDICINE OPD AFTER 1 WEEK


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