Day 1 (17/3/14)
This 51-year-old Malay lady with a 15-year history of hypertension but defaulted treatment presented with shortness of breath and productive cough for 1 week. There were also complaints of fever, occasional pleuritic chest pain, palpitations, dizziness, decreased effort tolerance, orthopnoea and paroxysmal nocturnal dyspnoea which worsened since a week ago. On admission, patient was mildly tachypnoeic but was able to speak in short sentences. Blood pressure was very elevated-220/100mmHg with tachycardia (PR=120 bpm, regular, no radioradial or radiofemoral delay) and tachypnoea (RR=28 breaths/min). This indicates she may be in hypertensive crisis state. However, she does not have blurring of vision, neurological deficits, or urine alteration. Temperature was 37.5 deg. There are features of cardiac failure such as raised JVP, bibasal crepitations with scattered ronchi and mild pitting edema bilaterally until the knee.
Investigations revealed confirmed an elevated TWC, low potassium, and elevated LDH levels. Trop-I was <0.02. Lipid levels were elevated. Chest X-ray showed cardiomegaly with bilateral lower zone haziness and ECG interpretation was left ventricular hypertrophy with T-wave inversion on the inferior leads. She was treated as community acquired pneumonia (CAP) with acute pulmonary edema (APO) secondary to ischemic heart disease complicated by uncontrolled hypertension. She was started on IVI GTN 50mg 0.9ml/hr with IV Lasix 40mg BD for her APO and T. Amlodipine 10mg stat & OD for her hypertension. IV Augmentin 1.2g stat & TDS with T. Doxycycline 20mg stat &100mg OD was given for the underlying lung infection. T. Simvastatin was given due to the deranged lipid profile, and T. Slow K 11/11 TDS was given for the low potassium level. Post-treatment review showed BP reduced slightly to 180/92mmHg, and T. HCTZ 25mg stat & OD was added. She was also on fluid restriction of 1L/day.
Day 2 (18/3/14)
Patient is on Day 2 of IV Augmentin and T. Doxycycline. However, her TWC is still high (16.6-->21.9). She claims to have reduced breathlessness but has occasional mild chest pain with no palpitations. Her cough has also improved slightly. There are still bibasal crepitations with ronchi heard upon lung examination with mild pedal edema. IVI GTN 50mg is increased to 1.5mls/hr and IV Lasix is also increased to 40mg TDS. She is also given Neb AVN 2:1:1 stat and 4-hourly for her crepitations. Her fluid restriction is reduced to <500ml/day. There is no improvement in the BP since yesterday (195/105mmHg), hence T. Amlodipine is replaced with T. Felodipine 10mg BD. The nurse is told about monitoring the BP hourly.
Daily ECG shows inversed T-waves at the inferior leads, and cardiac enzymes are elevated. This indicates that the patient has acute coronary syndrome (ACS) and is warranted to start on S/C Fondaparinoux 2.5mg stat & OD, T. Cardiprin 100mg OD, T. ISMN 30mg OD, and IV Pantoprazole 40mg OD in view of NSTEMI. Potassium level is still low (2.9-->2.5) despite being given T. Slow K, most likely due to the increased dose of IV Lasix given. She is also referred for chest physiotherapy and we have also addressed the issue of non-compliance of this patient. She said that she did not feel like taking medications when she could not see the effect despite the clinic being 10 minutes away from home. After counselling the patient on the possible complications that may arise, the need for continuation of care and the importance of follow-ups, she finally agrees to comply with any future management plans.
Day 3 (19/3/14)
Patient is on Day 3 of IV Augmentin and T. Doxycycline. She is currently treated as decompensated CCF secondary to CAP/ACS. Patient claims to have reduced breathlessness and chest pain but there is still occasional productive cough. Her blood pressure has reduced to 155/95mmHg but she currently has fever (Temp: 37.8 deg). She still has slight tachypnoea and lung auscultation reveals mild bibasal crepitations with occasional ronchi. We continued the antibiotics for this patient. She is also on Day 2 of S/C Fondaparinoux. We had stopped the IV GTN and reduce the IV Lasix dose to 40mg BD. T. HCTZ dose is increased to 50mg OD and Mist KCl 15mls TDS is added in view of the low potassium level (2.5-->2.6). She is still continued on Neb AVN 4-hourly and she is allowed fluid restriction of <1L/day.
Day 4 (20/3/14)
Patient is on Day 4 of antibiotics. Currently, she does not have any shortness of breath and she isn't tachypnoiec. Her blood pressure is 149/81mmHg and she is afebrile. There are still crepitations heard over the left lower lung zone with no ronchi. The plan is to stop giving oxygenation via nasal prong since she was able to sustain an SpO2>95% under room air. Her nebulisation is reduced to 6-hourly and she is planned to complete her dose of S/C Fondaparinoux today. She is also given Ravin enema stat due to poor bowel output for the past 3 days. T Bisoprolol 2.5mg stat and OD is added to the list of medications and IV Lasix is changed to T. Lasix 40mg OD. She was transferred out to Ward 6 in view of improving symptoms.
Day 5 (21/3/14)
Patient is currently comfortable, with no active complaints. She is keen on going home. Her blood pressure is still slightly elevated (160/90mmHg) but she is afebrile. Crepitations are still heard over the left lower zone of the lung. ECHO done shows reduced EF (25-30%) with LV dilation and poor LV function. Cardiac enzymes are still elevated but is on a decreasing trend, with an ECG reading of T wave depression on inferior leads. This supports the provisional diagnosis of CCF secondary to CAP/ACS. She is also having acute kidney injury (AKI) as her urea and creatinine values were suddenly elevated by 4-fold (Urea: 4.6-->16.3; Creat: 123-->410). We withhold T. Lasix as we suspect that may be the cause for her AKI. A repeat RP done later showed a urea value of 17.2 and creatinine:289 (Creatinine value decreasing). She still has hypokalemia but it is on a rising trend (2.6-->3.0). Currently, we increased the dose of her T. Bisoprolol to 5mg OD for a better control of her hypertension and we stopped her Neb AVN in view of improving symptoms. All the other medications are continued.
Day 6 (22/3/14)
Patient is on Day 6 of antibiotics and currently she has no active complaints. Her current BP reading is 115/82 and there are still minimal crepitations heard over the left lower lung zone. Her RP has been improving after we stopped T. Lasix (Current RP: Urea: 17.0/Na: 135/K: 3.6/ Creat: 213). Our current suspicion is that the AKI is caused by dehydration secondary to overdiuresis. Potassium values are finally within normal range and we stopped giving her T. Slow K and Mist KCl. Her cardiac enzymes are also on a decreasing trend. If the RP is maintained on a decreasing trend, we can discharge her out from the ward tomorrow.
Day 7 (23/3/14)
Patient is on Day 7 of antibiotics and has completed the regime. Blood pressure reading is 130/64mmHg (within normal range) and minimal crepitations were still heard over the left lower lung zone. Her current RP is 15.9/134/3.1/176. Since the RP values are decreasing, she is allowed discharge with a follow-up at KK Senggarang in 3 months to review back her renal profile and monitor her blood pressure readings. Her current discharge plan is to restrict her fluids to 500ml, restart T. Lasix 20mg OD, increase the T. Bisoprolol to 7.5mg OD, stop her HCTZ and Mist KCl medications and continue her other medications. We also counselled the patient to get T. Plavix 75mg OD from the pharmacy outside as hospital has no more stock. Patient agrees to do so and before she left, I reminded her about staying compliant to the fluid restriction, medications and follow-ups. Her final diagnosis was community acquired pneumonia (treated) with congestive cardiac failure secondary to NSTEMI, complicated by uncontrolled hypertension and acute kidney injury.
Investigations revealed confirmed an elevated TWC, low potassium, and elevated LDH levels. Trop-I was <0.02. Lipid levels were elevated. Chest X-ray showed cardiomegaly with bilateral lower zone haziness and ECG interpretation was left ventricular hypertrophy with T-wave inversion on the inferior leads. She was treated as community acquired pneumonia (CAP) with acute pulmonary edema (APO) secondary to ischemic heart disease complicated by uncontrolled hypertension. She was started on IVI GTN 50mg 0.9ml/hr with IV Lasix 40mg BD for her APO and T. Amlodipine 10mg stat & OD for her hypertension. IV Augmentin 1.2g stat & TDS with T. Doxycycline 20mg stat &100mg OD was given for the underlying lung infection. T. Simvastatin was given due to the deranged lipid profile, and T. Slow K 11/11 TDS was given for the low potassium level. Post-treatment review showed BP reduced slightly to 180/92mmHg, and T. HCTZ 25mg stat & OD was added. She was also on fluid restriction of 1L/day.
Day 2 (18/3/14)
Patient is on Day 2 of IV Augmentin and T. Doxycycline. However, her TWC is still high (16.6-->21.9). She claims to have reduced breathlessness but has occasional mild chest pain with no palpitations. Her cough has also improved slightly. There are still bibasal crepitations with ronchi heard upon lung examination with mild pedal edema. IVI GTN 50mg is increased to 1.5mls/hr and IV Lasix is also increased to 40mg TDS. She is also given Neb AVN 2:1:1 stat and 4-hourly for her crepitations. Her fluid restriction is reduced to <500ml/day. There is no improvement in the BP since yesterday (195/105mmHg), hence T. Amlodipine is replaced with T. Felodipine 10mg BD. The nurse is told about monitoring the BP hourly.
Daily ECG shows inversed T-waves at the inferior leads, and cardiac enzymes are elevated. This indicates that the patient has acute coronary syndrome (ACS) and is warranted to start on S/C Fondaparinoux 2.5mg stat & OD, T. Cardiprin 100mg OD, T. ISMN 30mg OD, and IV Pantoprazole 40mg OD in view of NSTEMI. Potassium level is still low (2.9-->2.5) despite being given T. Slow K, most likely due to the increased dose of IV Lasix given. She is also referred for chest physiotherapy and we have also addressed the issue of non-compliance of this patient. She said that she did not feel like taking medications when she could not see the effect despite the clinic being 10 minutes away from home. After counselling the patient on the possible complications that may arise, the need for continuation of care and the importance of follow-ups, she finally agrees to comply with any future management plans.
Day 3 (19/3/14)
Patient is on Day 3 of IV Augmentin and T. Doxycycline. She is currently treated as decompensated CCF secondary to CAP/ACS. Patient claims to have reduced breathlessness and chest pain but there is still occasional productive cough. Her blood pressure has reduced to 155/95mmHg but she currently has fever (Temp: 37.8 deg). She still has slight tachypnoea and lung auscultation reveals mild bibasal crepitations with occasional ronchi. We continued the antibiotics for this patient. She is also on Day 2 of S/C Fondaparinoux. We had stopped the IV GTN and reduce the IV Lasix dose to 40mg BD. T. HCTZ dose is increased to 50mg OD and Mist KCl 15mls TDS is added in view of the low potassium level (2.5-->2.6). She is still continued on Neb AVN 4-hourly and she is allowed fluid restriction of <1L/day.
Day 4 (20/3/14)
Patient is on Day 4 of antibiotics. Currently, she does not have any shortness of breath and she isn't tachypnoiec. Her blood pressure is 149/81mmHg and she is afebrile. There are still crepitations heard over the left lower lung zone with no ronchi. The plan is to stop giving oxygenation via nasal prong since she was able to sustain an SpO2>95% under room air. Her nebulisation is reduced to 6-hourly and she is planned to complete her dose of S/C Fondaparinoux today. She is also given Ravin enema stat due to poor bowel output for the past 3 days. T Bisoprolol 2.5mg stat and OD is added to the list of medications and IV Lasix is changed to T. Lasix 40mg OD. She was transferred out to Ward 6 in view of improving symptoms.
Day 5 (21/3/14)
Patient is currently comfortable, with no active complaints. She is keen on going home. Her blood pressure is still slightly elevated (160/90mmHg) but she is afebrile. Crepitations are still heard over the left lower zone of the lung. ECHO done shows reduced EF (25-30%) with LV dilation and poor LV function. Cardiac enzymes are still elevated but is on a decreasing trend, with an ECG reading of T wave depression on inferior leads. This supports the provisional diagnosis of CCF secondary to CAP/ACS. She is also having acute kidney injury (AKI) as her urea and creatinine values were suddenly elevated by 4-fold (Urea: 4.6-->16.3; Creat: 123-->410). We withhold T. Lasix as we suspect that may be the cause for her AKI. A repeat RP done later showed a urea value of 17.2 and creatinine:289 (Creatinine value decreasing). She still has hypokalemia but it is on a rising trend (2.6-->3.0). Currently, we increased the dose of her T. Bisoprolol to 5mg OD for a better control of her hypertension and we stopped her Neb AVN in view of improving symptoms. All the other medications are continued.
Day 6 (22/3/14)
Patient is on Day 6 of antibiotics and currently she has no active complaints. Her current BP reading is 115/82 and there are still minimal crepitations heard over the left lower lung zone. Her RP has been improving after we stopped T. Lasix (Current RP: Urea: 17.0/Na: 135/K: 3.6/ Creat: 213). Our current suspicion is that the AKI is caused by dehydration secondary to overdiuresis. Potassium values are finally within normal range and we stopped giving her T. Slow K and Mist KCl. Her cardiac enzymes are also on a decreasing trend. If the RP is maintained on a decreasing trend, we can discharge her out from the ward tomorrow.
Day 7 (23/3/14)
Patient is on Day 7 of antibiotics and has completed the regime. Blood pressure reading is 130/64mmHg (within normal range) and minimal crepitations were still heard over the left lower lung zone. Her current RP is 15.9/134/3.1/176. Since the RP values are decreasing, she is allowed discharge with a follow-up at KK Senggarang in 3 months to review back her renal profile and monitor her blood pressure readings. Her current discharge plan is to restrict her fluids to 500ml, restart T. Lasix 20mg OD, increase the T. Bisoprolol to 7.5mg OD, stop her HCTZ and Mist KCl medications and continue her other medications. We also counselled the patient to get T. Plavix 75mg OD from the pharmacy outside as hospital has no more stock. Patient agrees to do so and before she left, I reminded her about staying compliant to the fluid restriction, medications and follow-ups. Her final diagnosis was community acquired pneumonia (treated) with congestive cardiac failure secondary to NSTEMI, complicated by uncontrolled hypertension and acute kidney injury.
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