CASE DISCUSSIONDR.W.A.P.S.R. WEERARATHNA

REGISTRAR-WD 10/02

Mrs. Nisamany , a 69 year old mother 0f three from Alwai.

She is a house wife & diagnosed to have Hypertension for last 10 years of duration.

She was apparently well with regular clinic follow up & treatment untill 5 months back.

While on regular medication she devaloped an atypical left sided chest pain where that episode was lasted more than 20 minutes,with associated autonomic symptoms but no radiation.

Since she was breathless & had alterd sensorim, she was admitted to THJ within hours.

After being admitted to the ED she was transferred to the MICU where she had a 5 days of stay.

During her hospital stay she experienced recurrent episodes of chest pain where she was given IV medication & underwent several investigations.

She gradually devaloped bilateral ankle oedema & breathlessness wich responded to medication within few days.

Her urine output was gradually reduced over time but she was not offered any kind of RRT.

Her chest pain was not pleuritic in nature and she denied any productve cough,episodes of haemoptysis.

Pain was not radiating to the back. She had no H/O any long journey prior to

that episode & she was bed bound. She had a ward stay of 2 days inaddition &

she was refferdr to the cardiologist for further evaluation.

After the discharge she was prescribed several other medication & was asked to fillow up in the clinic with certain life style modifications.

She has no H/O stroke or TIA . She denies intermittent claudication of

lower limbs There is no recent H/O a sudden or incidious

dererioration of her vision. She didn’t have F/O LUTS or BOO, While on regular medication, after about 2

months she had a second episode of chest pain …

….which was ischaemic type & warrented her a admission to THJ & subsequent MICU are for the second time.

This time it was much dramatic & associated with NYHA tpe 3-4 grade SOB.

UOP was also reduced markedly but managed conservatively.

After 3 days of MICU care she recoverd & cardiology refferal was made & she was subjected to an USS of abdomen as well.

PMH- was not complicated with a H/O DM,Dislipidaemia,BA,Urilithiasis or any malignancies.

PSH- NOT significant. Gyn Hx- she attained menuoause at the age

of 50 years. DH-she had been on anti hypertensives &

lateron started on antianginals.Drug compliance was satisfactory.

Dietary Hx-she is not a vegitarian. Allergy Hx-not signiicant.

FH-there is no premature death due to a acute coranary event among 1st degree relatives.

SH-she doesn’t take alcohol.she has a fairly good family support & her knowledge regarding her current disease stasus is satisfactory.

Not pale Afebrile BMI- 25.4 kg/m2 Not dyspnic Not cyanosed No B/L ankle oedaema No xanthesma No peripheral stgimata of IE

EXAMINATION

CVS Exam- BP-170/90 mmHg, PR-88/min ,DR+, ESM+ Apex- 6th ICS in 2 cm lateral to MCL All peripheral pulses present with no R-R or

R-F delay No B/L fine basal crepitations AS Exam- No organomegaly, No expansile

or transmitted pulsations, bruit + just above & lateral to the umbilicus

RS Exam- unremarkable.

CNS Exam-No objective weakness of limbs,no focal neurological deficites, Fundoscopy- L/S 9 ‘0clock position hard exudate+

A 69 year old lady with a H/O HTN on treatment with good compliance has had 2 hospital admissions with subsequent MICU care within 4 months duration. Hx was complicated with NYHA grade 3-4 SOB & oliguria. On clinical exam she had moderate cardiomegaly, ESM+, abdominal bruit, & L/S retinal exudate.

SUMMARY

INVESTIGATIONS

1 2 3 4 5 6 7 8 9 10 11 12

FBC 19/03/14 24/03/14

Hb 15.7 14.7

PCV 45 43

MCV 88.5 84

MCH 28.8 29.1

MCHC 32 32

WBC 10.2 9,9

PLT 287 234

N 67 71

L 22 08

FBC

RFT 19/03 22/03 23/03 24/03 20/06

BU 22.7 34 44 34 40

S.Cr 1.4 1.9 1.5 1.2 0.95

S.Na+ 134 142 129 135 138

S.K+ 3.0 2.6 3.1 2,8 3.1

RFT

BU- 117 mg/dl S.Cr- 1.9 mg/dl S.uric acid- 11.5 mg/dl PO4- 3.40 mg/dl K+- 2.0 mmol/l- Na+- 134 mmol/l- Cl- 81 mmol/l-

RENAL PROFILE

90 mg/dl

FBS

TC- 211 mg/dl HDL-C 36 mg/dl LDL-C TG 280 mg/dl VLDL-C 53 mg/dl TC/HDL-C 0.6

LIPID PANEL

LAD+ T inversion/ Stdepression V2-V6 Voltage criteria for LVH+

ECG

POSITIVE- 0.328 mg.dl

cTnI

CXR-PA-on admission

CXR-PA-after theraphy

LVEF-60% No RWMA Concentric LVH+ Degenarative valves Otherwise Normal study

2D-Echocardiograme

Liver/GB/Spleen-Normal Right kidney -7.8cm,smaller,CMD

Presserved,no supra renal masses Left kidney-10 cm,echogenic,normal in

shape,normal CMD,Both kidneys no hydronephrosi,no calculi.

Bladder normal,uterus normal,no ascites Right renal artery doppler was not convinced

due to inadequate breath holding. Right kidney is smaller than left,probable

renal artery stenosis cannot be excluded. CTA would be helpful.

USS-Abdomen-03/03/14

R-Kidney-7.6cm L-Kidney-9.8cm R/S Renal artery appear small in caliber

from hypoplastic R kidney Both renal arteries show narrowing at the

ostea from the arota. Diagnosis- B/L renal artery stenosis at the

site of origin Sugest DSA & Balloon angioplasty of

renal arteries-Vascular refferal.

CTA-24/03 /14

CTA cont…

CTA cont…

CTA

DSA

DIAGNOSIS/DIFFERENTIAL DIAGNOSIS?

ANGIOPLASTY OF LEFT RENAL ARTERY

THANK YOU!