Day 1 (3/3/14)
This 73-year-old Malay gentleman with
underlying diabetes mellitus and hypertension presented to the hospital with
non-productive cough and shortness of breath, for the past 2 weeks. There were
also complaints of progressive bilateral leg swelling as well as orthopnoea and
paroxysmal
nocturnal dyspnoea which worsened since 2 weeks ago. In addition, he also
had dizziness and loss of appetite with no loss of weight. When first seen in
the hospital, he was tachypnoeic and pale, with signs suggesting cardiac
failure such as bibasal crepitations and bilateral pedal edema. His random
blood glucose level was high – 20mmol/L. Investigations showed microcytic
hypochromic anemia findings (Hb 4.9/ MCV 54.8) with elevated ALP, GGT and CK
enzyme. Chest X ray showed cardiomegaly with bilateral perihilar haziness and
blunted right costophrenic angle. He was treated as congestive cardiac failure (CCF)
with community acquired pneumonia (CAP). He was transfused 1 unit of packed
cell blood and given IV Lasix 20mg post-transfusion. S/C Actrapid 8 units TDS and
S/C Insulatard 12 units ON were given and glucose levels were monitored.
Day 2 (4/3/14)
Currently, patient is comfortable with improving
breathlessness and coughing. However, he still experience dizziness, especially
when standing for long periods or walking. He has mild abdominal discomfort and
manage to pass motion once today. Patient claimed that he defaulted treatment
for one year due to transportation issues, but his wife said that he refused to
seek treatment. He is counselled regarding the need for continuation of care
and the importance of follow-ups. No change in examination findings and blood
glucose level is still high – 16.0mmol/L. Post-transfusion Hb is still low – 6.0.
Another unit of packed cells blood is transfused and keep NPO2 at 2L/min. IV Augmentin
1.2g TDS and T. Erythromycin 800mg BD is started and iron study with peripheral
blood film (PBF) is ordered.
Day 3 (5/3/14)
Patient has completed 2 units of packed cells blood
transfusion. Currently, he is on Day 2 IV Augmentin and T. Erythromycin. There
are no complaints of breathlessness but there is still dizziness present.
Glucose level is 10.3mmol/L. There are still bibasal crepitations heard in both
lung fields. Post-transfusion Hb is still low – 6.8, so 2 units of packed cell
blood will be transfused tonight. Iron study and PBF results show severe iron
deficiency anemia. FBG is 11.4mmol/L. He is on fluid restriction of <1L/day,
T. Simvastatin 40mg ON, IV Lasix 40mg TDS and T. Hematinics. Insulin regime is
continued.
Day 4 (6/3/14)
Currently, patient has completed 4 units of packed cells blood transfusion. He is on Day 3 of IV Augmentin and T. Erythromycin. He complained of greenish stool but no gastritis noted. PR shows hematinic stools with no blood stain. He was referred to the surgical team for an OGDS to rule out upper gastrointestinal bleeding as the cause of the anemia. Blood glucose level is 11.2mmol/L. Post-transfusion Hb is 8.9 and ECHO result shows good LV function with EF 60-65%, which rules out diagnosis of cardiac failure.
Day 5 (7/3/14)
Currently, patient is comfortable under room air and he is on Day 4 of IV Augmentin and T. Erythromycin. He is still clinically pale and the crepitations are still not resolved. Another unit of packed red cells is transfused with the aim to increase the Hb>9.0. The medications are changed to T. Lasix 40mg BD and T. Augmentin 625mg BD and the surgical team can continue with their management plan. Allow discharge of the patient to the surgical team if the patient is afebrile.
Day 6 (8/3/14)
Patient is on Day 5 of T. Erythromycin (completed). Vital signs of the patient are normal and he has no fever. Post-transfusion Hb is 9.8.Since there is no active medical intervention, we have referred the patient to the surgical team to take over.
Day 7 (9/3/14)
Patient’s case notes and progress is seen by Dr Quek and currently, the patient do not have any active complaints. Patient has no hypoglycemic symptoms despite having blood glucose level at 3.4mmol/L. The insulin regime is changed to oral anti-diabetic agents of Gliclazide and Metformin. We counselled the patient regarding good glycemic control and possible complications of uncontrolled diabetes mellitus. The final diagnosis made is community acquired pneumonia with right-sided parapneumonic effusion with iron deficiency anemia to rule out gastrointestinal bleeding and underlying uncontrolled diabetes mellitus and hypertension.
This is a reasonably good summary and progress report. An elderly man with poorly controlled diabetes and severe anemia is initially admitted with a diagnosis of CCF. He also has hypertension. He is treated with insulin, diuretics and given blood transfusions. He improves with this treatment. The anemia is suspected to be due to GI bleeding and a surgical referral was made. He seemed to be in danger of developing hypoglycemia with insulin and hence his insulin was stopped and he was treated instead with OHA.
ReplyDeleteMy comments are:
1. There is no mention of his BP even though he is a known hypertensive
2. There is no mention of his renal function which seems to be very important in view of his diabetes and hypertension and anemia.
3. The notes do not suggest any possibilities for the suspected GI hemorrhage. I wonder if he could have a malignancy in the stomach.
4. It seems to me that determining the cause of his anemia is a priority and I wonder why an OGDS was not done before discharge.
Dear Dr Vela,
Delete1. The systolic blood pressure reading for this patient for the past few days were within 100-130 mmHg.
2. His renal function were all within the normal range as well.
3 & 4. The patient was reviewed by the surgical team during admission and an OGDS was done after the review. They noted mild erosions over the stomach and duodenum lining, and the surgical team made a diagnosis of gastritis and duodenitis. He was only discharged to the surgical ward to undergo a colonoscopy scheduled on 11/3/14 to find for the cause of the bleeding.