Left ventricular failure with parkinsons disease and hypertension with type 2 dm

1

Case presentation on left ventricular failure with Parkinson's disease and type 2 DM with hypertensionPresented by : Abhimanyu parashar 5th Pharm.D roll no. 1

Saturday 8 April 20232

IP no. : 223050

UNIT : medicine 1

AGE : 70 yrs

SEX : Female


Reasons for admission :c/o :

Generalized weakness x 2 days Inability to move x 2 days


General examination An elderly female , moderately built and

nourished , conscious and cooperative Pulse : 94 BPM BP :140/90 mmHg SPo2 : 94% CBG : 169 mg/dl No meningeal signs


Pallor + No cyanosis , no clubbing CNS : cranial nerves normal P/A : soft and non tender Power :

Tone :

U/L L/LR 3/5 3/5L 4/5 4/5

U/L L/LR N NL N N


DTR : RIGHT LEFT

B +++ ++T ++ ++S ++ ++K +++ ++A +++ ++Plantar increased Normal


PMHx : K/C/O type 2 DM x 8 years and was on

glimipride and metformin (½-0-0) K/C/O hypertension x 8 yrs and was on

losartan (1-0-0) H/O of seizures disorders .


Allergies FHx SHx

NKA NS NS


Personal history DIET : veg

APPETITE : good

SLEEP : undisturbed

BOWEL and BLADDER : normal and regular


PROVISIONAL DIAGNOSIS

TYPE 2 DM with TRANSIENT ISCHEMIC ATTACK


DAY NOTES :


DAY 1 BP : 140/80 mmHg PULSE : 94 BPM SPo2 : 94% CBG :169 mg/dl C/O : generalized weakness since 2 days Unable to move around since 2 days Difficulty in moving all 4 limbs


O/E : CVS: S1S2 present and no murmurs RS: NVBS + , no added sounds CNS: Patient is conscious oriented and

cranial nerves are normal No atrophy or hypertrophy of musclesADV : treatment as per chart ,

Hb ,TC , DC , RBS , Urea , electrolytes


LAB REPORTS :


Hematology

Hb 9.7 g%

RBC 4.18 million cells/cumm

PLT 1.17 L/cumm

WBC 4300

DLC :N 65%

E 04%

B 31%

L 00%

M 00%

ElectrolytesNa 144 mmol/l (135-147)K 4.8 mmol/l (3.5-5.0)Cl 102 mmol/l (95-105)

HbA1C

10.6 (4.0-6.0)

RBS 73 mg/dl (70-150)Urea 20 mg/dl (0-40)

Urine analysisPus cells 2-4Epithelial cells

1-2IMP : microcytic hypo chromic anemia with thrombocytopenia


TREATMENTDRUGS DOSE ROUTE FREEQUEN

CYInj. Actrapid 6-6-6

unitsSC 1-1-1

Tab. atorvastatin 40 mg PO 0-0-1Tab. Aspirin and clopidogrel

150 mg PO 0-1-0


DAY 2 BP : 140/90 mm Hg PULSE : 92 BPM CBG : 107 mmHg O/E : CVS / RS – NAD PA : soft and non tender ADV : treatment as per chart , LFT ,

CKMB , Troponin-I , ortho-opinion for knee osteoarthritis.

Ortho ADV : X ray for both knee standing


LFTAST 94 (0-40)ALT 41 (0-40)ALP 665 (37-147)Billirubin Total 2.60 mg/dl(0.1-

1.0)Direct 1.30 mg/dl(0-0.2)

BiochemistryRBS 216 mg/dlFBS 93 mg/dlPLT 98000 cells/cumm

Lipid profileHDL 35 mg/dl (30-70)LDL 43 mg/dl (60-130)VLDL 16 mg/dl (5-40)TG 82 mg/dl (10-190)

Cardiac enzymesCKMB 44 U/L (0-20)Troponin I

0.002 ng/ml (Less than 0.035 ng/ml)


IgM dengue : NS 1 Ag : negativeIgM anti dengue : not detected

Widal test : negative QBC-MP : negative




unitsSC 1-1-1

Tab. Atorvastatin 40 mg PO 0-0-1Tab. aspirin and clopidogrel

150 mg PO 0-1-0

Inj.trineurosol .H 1 cc IV 1-0-0


DAY 3 BP : 140/90 mm Hg PULSE : 82 BPM O/E : CVS/RS – NAD ADV : 2-D ECHO , Carotid doppler,

Optho opinion


Ophthalmology opinion :IMP : no evidence of diabetic

nephropathy

Normal fundus


TREATMENTDRUGS DOSE ROUT

EFREEQUEN


unitsSC 1-1-1

Tab. atorvastatin 40 mg PO 0-0-1Tab. aspirin and clopidogrel

150 mg PO 0-1-0

Inj. Trineurosol.H 1 cc IV 1-0-0


DAY 4 BP : 140/80 mm Hg PULSE : 82 BPM RS/CVS : NAD


At 6:15 PM Not conscious , not responding to oral

commands from afternoon BP : 140/70 mmHg Pulse : 72 BPM SpO2 : 97% CVS : S1S2 + no murmurs RS : NVBS + CNS : responds to deep painful stimuli


Motor system : B/L plantar extension Reflex :

ADV : CT scan , ECG , shift to emergency ward , ABG , U/C , SE

Right LeftUpper limb Decreased Present Lower limb Absent Decreased


Prothrombin timeControl 13.5 secPatient 30.2 secRatio 2.22Index 44.7INR 2.223 (0.8-1.2)

electrolytesNa 138 mmol/lK 3.6 mmol/lCl 104 mmol/lCa 9.0 mmol/l (8.8-

10.8)P 3.6 mmol/l (2.5-5.0)Mg 1.7 mmol/l (1.7-2.7)

LFTAST 170 ALT 104ALP 560Billirubin – total

1.60

direct

1.14biochemistry

Urea 36 mg/dlS. Cr 1.0 mg/dl (0.8-1.4)

Total protein

7.0 g/dl(6-8)

Albumin 4.0 g/dl (3.4-5.0)A/G 1.3 (1.2-2.5) GFR :49.6 ml/min


ABG report pH 7.48 (7.34-7.44)

PCo2 24.4 (35-45 mmHg)

HCo3 18.1(22–26 mEq/L)

PO2 107.5 (75-100 mmHg)

BE -4.3 (−2 to +2 mmol/L)

TCo2 18.9(100-132mg/dl)



EFREEQUEN


unitsSC 1-1-1


150 mg PO 0-1-0

Inj. Trineurosol.H 1 cc IV 1-0-0Tab. piracetam 400 mg PO Q8HR.T. feeds 200 ml Q3H


DAY 5 BP : 140/80 mm Hg PULSE : 108 BPM SpO2 : 98% CBG : 130 mg/dl O/E : Patient responds to simple oral

commands , eye movements + Afebrile , no pedal edema


CVS : S1S2 + , no murmur R/S : B/L NVBS + , no added sounds CNS : patient responds to verbal

commands B/L plantar withdrawal Pupil : reactive Moves all 4 limbs . Mild terminal neck

stiffness. Doll eye movement + Cough reflex +


ECG : heart rate 100 / minute Sinus rhythm + axis . T inversion V2V6 ADV : RT feeding 200 ml Q3H , perform CBG

Q8H , IVF NS@ 30 ml/Hr , weil Felix test Weil felix test : negative CST and neurologist opinion .NEURO OPINION : Pt stuporous , max response to painful stimuli ,

maximum movements of limbs Add SYNDOPA (LEVODOPA + carbidopa)

110 mg ½ ½ ½ CT head : not significant ADV : LP-CSF analysis , may require MRI

scan


TREATMENTDRUGS DOSE ROU

TEFREEQUENCY

Inj. Actrapid 6-6-6 units

SC 1-1-1


150 mg PO 0-1-0

Inj. Trineurosol.H 1 cc IV 1-0-0Tab. piracetam 400 mg PO Q8HR.T. feeds 200 ml Q3HT.syndopa 110 mg PO ½ ½ ½


DAY 6 BP : 140/80 mm Hg PULSE : 100 BPM O/E : patient responds to oral commands

by opening eye SPO2 : 98% CVS : S1S2 + , no murmurs RS : B/L NVBS + CNS : patient stuporous , response to

painful stimuli , B/L plantar --


B/L : pupil 4 mm reactive , doll eye movement + , cough reflex +

ADV : Repeat PLT count , USG abdomen , CXR- PA view , MRI brain

USG abdomen : normal MRI report : old infarction , doesn't

explain clinical state


CXR - PA view showing NORMAL and CARDIAC HYPERTROPHY



EFREEQUEN


unitsSC 1-1-1

Tab. Atorvastatin 40 mg PO 0-0-1Tab. aspirin and clopidogrel

150 mg PO 0-1-0

Inj. Trineurosol.H 1 cc IV 1-0-0Tab. Piracetam 400 mg PO Q8Htab. Doxycyclin 100 mg PO ½- ½ - ½ R.T. feeds 200 ml Q3HT.syndopa 110 mg PO ½ ½ ½


DAY 7 BP : 160/80 mm Hg PULSE : 102 BPM SPO2 : 98% O/E : patient responds to oral

commands with comprehensive sounds Spontaneous movements of all 4 limbs CVS : S1S2 + no murmurs


RS : B/L NVBS + no added sounds PA: soft and no organomegaly ECG : ST and T wave changes CNS : patient responds to deep pain

stimulation , spontaneous of all 4 limbs +

B/L plantar withdrawal , Cog-wheal rigidity : +

GCS : 8/15


1 2 3 4 5 6

EyesDoes not

open eyes

Opens eyes in

response to

painful stimuli

Opens eyes in

response to voice

Opens eyes

spontaneously

N/A N/A

VerbalMakes

no sounds

Incomprehensible sounds

Utters inapprop

riate words

Confused,

disoriented

Oriented, converses normally

N/A

MotorMakes

no moveme

nts

Extension to

painful stimuli

Abnormal flexion

to painful stimuli

Flexion / Withdra

wal to painful stimuli

Localizes painful stimuli

Obeys comman

ds

Glasgow Coma Scale

. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).

brain injury is classified as:•Severe, with GCS < 9•Moderate, GCS 9–12•Minor, GCS ≥ 13.


B/L : pupil 4 mm and reactive ADV : repeat platelet count, U/C ,

S/E , LP, CSF analysis . At 3:00 PM call attended for LP LP is done in L3 and L4 interspace

Clear and free flow of CSF , 24 drops each in 3 containers Post procedure : BP – 140/90 mmHg PULSE – 100 BPM SPO2 : 99% RS – B/L NVBS +


RBS 45 mg/dl (40-70)Protein 20 mg/dl (20-45)Chlorine 112 mg/dl (116-122 mg/dl)

CSF analysis report

0.1 ml clear fluid Cell count : 3 cells/cumm

Cell type : a few lymphocytesNon malignant cells in smear

CSF analysis reportGram stain No cells no organismZN stain No AFBIndia ink No cryptococcus


PLT 1.09 Lakhs/cumm

UREA 22 mg/dl

S.Cr 0.8 mg/dl

electrolytes

Na 128 mmols/L

K 3.6 mmols/L

Cl 103 mmols/L




unitsSC 1-1-1


150 mg PO 0-1-0

Inj. Trineurosol.H 1 cc IV 1-0-0Tab. piracetam 400 mg PO Q8Htab. Doxycyclin 100 mg PO ½- ½ - ½ R.T. feeds 200 ml Q3HT.syndopa 110 mg PO ½ ½ ½


DAY 8 BP : 170/100 mm Hg PULSE : 98 BPM O/E : CVS : S1S2+ , no murmurs Input/output : 2000/4000 FCBG : 130 mg/dl Pre dinner : 138 mg/dl RS : B/L NVBS +


CNS : responds to deep pain stimuli B/L plantar – Cog-wheel rigidity : + B/L pupil : 4 mm and reactive ECG : T wave inversion in V2 and V4

(ischemic) ST flat in II and III , avf ,V3 and V6



CYInj. Actrapid 6-6-6 units SC 1-1-1Tab. atorvastatin 40 mg PO 0-0-1Tab. aspirin and clopidogrel

150 mg PO 0-1-0

Inj. Trineurosol.H 1 cc IV 1-0-0Tab. piracetam 400 mg PO Q8Htab. Doxycyclin 100 mg PO ½- ½ - ½ R.T. feeds 200 ml Q3HT.syndopa 110 mg PO ½ ½ ½


DAY 9 BP : 140/70 mmHg PULSE : 84 BPM SPO2 : 94% ECG : t wave inversion an V1 and V6 CVS : S1S2 + , no murmurs RS : B/L NVBS + , no added sounds CNS : conscious oriented , responds to

commands


POWER : 4/5 Cog-wheel rigidity : + GCS : 9/15 B/L pupil : 4 mm and reactive B/L plantar : flexion ADV : 2D-ECHO


ECHO report Mildly dilated cardiac chambers Mild apical-septal hypokinesia Decreased LV systolic dysfunction EF : 36% LV diastolic dysfunction Sclerotic aortic valves with no significant

stenosis ( age related)



EFREEQUENCY

Inj. Actrapid 6-6-6 units

SC 1-1-1


150 mg PO 0-1-0

Inj. Trineurosol.H 1 cc IV 1-0-0Tab. piracetam 400 mg PO Q8Htab. Doxycyclin 100 mg PO ½- ½ - ½ T.syndopa 110 mg PO ½ ½ ½


DAY 10 BP: 120/80 , 140/70 mmHg PULSE : 90 BPM FCBG : 91 mg/dl Pre lunch : 169 mg/dl Pre dinner : 140 mg/dl O/E : patient is feeling better , conscious

, responds well to commands can be shifted to ward


RS : B/L NVBS + CNS : conscious oriented Power : 4/5 , all 4 limbs B/L plantar – B/L pupil Normal and non reactive ECG : HR – 100/ mt ST INVERSION with T wave

inversion an V2 an V6 ADV : shift to ward and CST



EFREEQUENC

YInj. Actrapid 6-6-6

unitsSC 1-1-1

Tab. Atorvastatin 40 mg PO 0-0-1Tab. aspirin and clopidogrel 150 mg PO 0-1-0Inj. Trineurosol.H 1 cc IV 1-0-0Tab. Piracetam 400 mg PO Q8HTab . Doxycyclin 100 mg PO ½- ½ - ½ Ranolazine 500 mg PO 1-0-1T.syndopa 110 mg PO ½ ½ ½


DAY 11 BP : 130/70 mmHg PULSE : 88 BPM O/E CVS / RS – NAD CNS : conscious oriented , POWER : 4/5 FCBG : 102 mg/dl Pre dinner : 189 mg/dl Bed sore : + ADV : wound care and CST


TREATMENTDRUGS DOSE ROUTE FREEQUENCY

Inj. Actrapid 6-6-6 units SC 1-1-1Tab. atorvastatin 40 mg PO 0-0-1Tab. aspirin and clopidogrel

150 mg PO 0-1-0

Tab. piracetam 400 mg PO Q8HTab. Ramipril 2.5 mg PO 1-0-0Cap. Cobadex PO 0-1-0ranolazine 500 mg PO 1-0-1

T.syndopa 110 mg PO ½ ½ ½


DAY 12 BP : 120/80 mmHg PULSE : 84 BPM CVS/RS : NAD PA : soft CNS : conscious oriented ADV : neurology opinion , CST , remove

IV line


TREATMENTDRUGS DOSE ROUTE FREEQUENC

YInj. Actrapid 6-6-6

unitsSC 1-1-1


150 mg PO 0-1-0

Tab. piracetam 400 mg PO Q8HTab. Ramipril 2.5 mg PO 1-0-0Cap. Cobadex PO 0-1-0ranolazine 500 mg PO 1-0-1T.syndopa 110 mg PO ½ ½ ½


DAY 13 BP : 120/70 mmHg PULSE : 88 BPM O/E : patient conscious oriented Bed sore + CVS : S1S2 heard RS : NVBS + FCBG : 103 mg/dl Pre dinner : 91 mg/dl ADV : CST


DAY 14 BP : 130/70 mmHg PULSE : 80 BPM Seen by neurologist O/E : responds to commands , rigidity of limbs

+ , no tremors , mask like face + Imp : early parkinsonism ADV : tab rasagiline 0.5 mg 0-1-0 Tab. Pramipexole 0.25 mg 1-0-1 Physiotherapy and CST Patient discharged against medical advice


Drugs D R F 1 2 3 4 5 6 7 8 9 10

11

12

13

14

Inj. Actrapid

6-6-6 units

SC 1-1-1 + + + + + + + + + + +

T. Atorvastatin

40 mg

PO 0-0-1 + + + + + + + + + + + + + +

T. aspirin and clopidogrel

150 mg

PO 0-1-0 + + + + + + + + + + + + + +

Inj. Trineurosol.H

1 cc IV 1-0-0 + + + + + + + + +

T. Piracetam

400 mg

PO Q8H + + + + + + + + + + +

T. syndopa 110 mg

PO ½ ½ ½

+ + + + + + + + + +

R.T. feeds 200 ml

Q3H + + + + + + + + + + + +

Treatment chart


Drugs D R F 1 2 3 4 5 6 7 8 9 10

11

12

13

14

Tab. doxycycllin

100 mg Po ½ -½ - ½

+ + + + +

T. Ramipril 2.5 mg Po 1-0-0 + + + + +

Cap. Ranolazine

500 mg Po 1-0-1 + + + + +

Cap. Cobadex

forte

Po 0-1-0 + + + +

H. mixtard 12-0-16units

SC + +

T. rasagiline

0.5 mg Po 0-1-0 +

Tab. pramiprax

ole

0.25 mg

po 1-0-1 +


PHARMACEUTICAL CARE PLAN (SOAP)


SUBJECTIVE EVIDENCEDiabetes Parkinson's disease

•Generalized weakness •Inability to move around•Reduced power•Stupor present•Mask like face


OBJECTIVE EVIDENCE Hypertension Diabetes Parkinson's

disease• Elevated blood

pressure• Elevated blood

glucose levels• Cog wheal

rigidity

Heart failure

•2-D ECHO report ( EF 36% )•Elevated AST•Elevated CKMB•ECG changes ( ST segment and T wave inversion)


FINAL DIAGNOSIS Based on objective and subjective

evidence the patient was diagnosed as early Parkinson's disease with left ventricular failure and type 2 Diabetes mellitus and hypertension


GOALS OF TREATMENT


For DIABETES to keep patients free of symptoms

associated with hyperglycemia or hypoglycemia (hunger, anxiety, palpitations, sweatiness).

primary goals of DM management are to reduce the risk for microvascular and macrovascular complications

to reduce mortality, and to improve quality of life


Index Goal

HB.A1C <7.0Preprandial capillary plasma glucose

5.0–7.2 mmol/L (90–130 mg/dL)

Peak postprandial capillary plasma glucose

<10.0 mmol/L (<180 mg/dL)

Blood pressure <130/80

Low-density lipoprotein <2.6 mmol/L (<100 mg/dL)High-density lipoprotein >1.1 mmol/L (>40 mg/dL)Triglycerides <1.7 mmol/L (<150 mg/dL)

Treatment Goals for Adults with Diabetes


For HYPERTENSION Treat systolic blood pressure to

recommended goal as primary focus (especially in patients older than 50 years).

Individualize all therapies based on compelling indications and comorbid conditions.

Ultimate treatment goal is the reduction of cardiovascular and renal morbidity and mortality


For CHF Minimize or prevent acute CHF

exacerbations Slow progression of CHF Increase survival


For PARKINSONS DISEASE Improve motor function Maintain ability to complete daily

activities independently Improve non-motor symptoms Maintain quality of life


TREATMENT OPTIONSFor cardiac complications

For diabetes For Parkinson's disease

ACE inhibitors •Ramipril

Anti anginals •Ranolazine

Anti hyper lipidemic•Atorvastatin

Anti platelets•aspirin and clopidogrel

Insulin •Human actrapid

•Human mixtard

Dopamine analogue•Levdopa

MAO inhibitors•rasagiline

Adjuvent treatments•Piracetam

•Vitamin supplements


GOALS ACHIEVED Signs and symptoms were improved BP was controlled and brought WNL Blood glucose was controlled and

brought WNL Patient gained consciousness


PROBLEMS IDENTIFIED Use of aspirin + clopidogrel in

patient with thrombocytopenia Use of doxycyclin even when weil

felix test was –ve PT/INR and cardiac enzymes were

not repeated


MONITORING PARAMETERS Disease related1. Blood pressure2. Blood glucose3. HbA1C4. ECG5. Cardiac enzymes6. Electrolytes 7. Motor symptoms


Drug related For insulin :Monitor hypoglycemic symptomsMonitor for lipid-dystrophy• For ramipril :Monitor serum potassium levelsMonitor blood pressure• For Levodopa :Monitor for motor symptoms and rigidity• For Aspirin and clopidogrel :Monitor blood platelet count • For Atorvastatin :Monitor plasma lipid levels


PATIENT COUNSELLING


About the disease(hypertension)


About the disease(Diabetes)

Signs and symptoms complications


About the disease(heart failure)


About the disease (PD)


About medication

Name and purpose

Dose and frequency

Medication adherence

Possible adverse effects

Missed dose


About life style modification

Healthy life style with daily exercise

(the ADA recommends 150 min/week (distributed over at least 3 days) of aerobic physical activity)

Self-Monitoring of Blood Glucose

Nutritional recommendations


DASH diet


Fat 20–35% of total caloric intakeSaturated fat < 7% of total calories<200 mg/day of dietary cholesterolTwo or more servings of fish/week provide -3 polyunsaturated fatty acids

Carbohydrate 45–65% of total caloric intake (low-carbohydrate diets are not recommended)Sucrose-containing foods may be consumed with adjustments in insulin dose

Protein 10–35% of total caloric intake (high-protein diets are not recommended)

Other components

Fiber-containing foods may reduce postprandial glucose excursions

Nonnutrient sweeteners


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THANK YOU

Left ventricular failure with parkinsons disease and hypertension with type 2 dm

Health & Medicine

Transcript of Left ventricular failure with parkinsons disease and hypertension with type 2 dm