LVF with HTN and T2DM and PD

1

left ventricular failure with Hypertension and type 2 DM

and Parkinson's disease

By: Abhimanyu Parashar Pharm.D Intern

Sunday 9 April 2023 2

• IP no. : 273050

• 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/L

R 3/5 3/5

L 4/5 4/5

U/L L/L

R N N

L 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).

• Allergies: NKA• FHx: NS• SHx: NS


PROVISIONAL DIAGNOSIS

TYPE 2 DM with TRANSIENT ISCHEMIC ATTACK


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


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


Hematology

Hb 9.7 g%

PLT 1.17 L/cumm

WBC 4300

DLC :

N 65%

E 04%

B 31%

L 00%

M 00%

Electrolytes

Na 144 mmol/l

K 4.8 mmol/l

Cl 102 mmol/l

HbA1C 6.6 g%

RBS 173 mg/dl

Urea 20 mg/dl

Urine analysis

Pus cells 2-4

Epithelial cells 1-2

IMP : microcytic hypo chromic anemia with thrombocytopenia


TREATMENT

DRUGS DOSE ROUTE FREEQUENCY

Inj. Regular Insulin 6-6-6 units SC 1-1-1

Tab. Atorvastatin 40 mg PO 0-0-1

Tab. Aspirin + clopidogrel 75 +75 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 , CKMB , Troponin-I

, lipid profile.• ortho-opinion for knee osteoarthritis. • Ortho ADV : X ray for both knee standing


Biochemistry

RBS 216 mg/dl

FBS 93 mg/dl

PLT 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 enzymes

CKMB 44 U/L (0-20)

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


TREATMENTDRUGS DOSE ROUTE FREEQUENCY



Tab. aspirin + clopidogrel 75 +75 mg PO 0-1-0

Inj. Multivitamin 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,

Ophthalmologist opinion• Ophthalmologists opinion : no evidence of

diabetic Retinopathy








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 extensor• Reflex :

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

Right Left

Upper limb Decreased Present

Lower limb Absent Decreased


Prothrombin time

Control 13.5 sec

Patient 30.2 sec

INR 2.223 (0.8-1.2)

electrolytes

Na 138 mmol/l

K 3.6 mmol/l

Cl 104 mmol/l

Ca 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)

LFT

AST 170 IU/L

ALT 104 IU/L

ALP 560 IU/L

Billirubin – total 1.60

direct 1.14

biochemistry

Urea 36 mg/dl

S. 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


TREATMENT



Tab. atorvastatin 40 mg PO 0-0-1



Tab. piracetam 400 mg PO Q8H

R.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 V2 V6• ADV : RT feeding 200 ml Q3H , 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


TREATMENT






Tab. Piracetam 400 mg PO Q8H

R.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


TREATMENT




Tab. aspirin and clopidogrel 150 mg PO 0-1-0



tab. Doxycyclin 100 mg PO ½- ½ - ½


T.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

Motor

Makes no

movements

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 report

Gram stain No cells no organism

ZN stain No AFB

India 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












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












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 : Extensor• ADV : 2D-ECHO


ECHO report

• Mildly dilated cardiac chambers • Mild apical-septal hypokinesia• LV systolic dysfunction +• LV diastolic dysfunction +• EF : 36%• Sclerotic aortic valves with no

significant stenosis ( age related)


TREATMENT










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/ min• ST INVERSION with T wave inversion

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





Tab. Aspirin + clopidogrel 75 +75 mg PO 0-1-0



Tab . Doxycyclin 100 mg PO ½- ½ - ½

Ranolazine 500 mg PO 1-0-1



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



Inj. Actrapid 6-6-6 units SC 1-1-1


Tab. Aspirin + clopidogrel 75 + 75 mg PO 0-1-0


Tab. Ramipril 2.5 mg PO 1-0-0

Tab Ranolazine 500 mg PO 1-0-1



DAY 12

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


TREATMENT






Tab. Ramipril 2.5 mg PO 1-0-0

ranolazine 500 mg PO 1-0-1



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 Relatives took the Patient against medical

advice .


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

11

12

13

14

Inj. Regular Insulin

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. Multivitamin 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 + + + + +

H. mixtard 12-0-16units

SC + +

T. rasagiline 0.5 mg Po 0-1-0 +

Tab. pramipraxole

0.25 mg po 1-0-1 +


PHARMACEUTICAL CARE PLAN (SOAP)


SUBJECTIVE EVIDENCE

Diabetes 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 and left ventricular failure with hypertension and type 2 Diabetes mellitus


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 <7.0

Preprandial 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 & HF

• Treat systolic blood pressure to recommended goal as primary focus (especially in patients older than 50 years).

• Minimize or prevent acute CHF exacerbations• Slow progression of CHF • Ultimate treatment goal is the reduction of

cardiovascular and renal morbidity and mortality

• Increase survival & improve HRQOL


For PARKINSONS DISEASE• Improve motor function • Maintain ability to complete daily

activities independently • Improve non-motor symptoms • Maintain quality of life


TREATMENT OPTIONSFor Heart Failure For diabetes For Parkinson's disease

• ACE inhibitors

• Beta Blockers

• Diuretics / Spironolactone

• Digoxin

Anti hyper lipidemic

Anti platelets

• Insulin

• OHA’s

• Dopamine analogue

• Peripheral Decarboxylase Inhibitors

• MAO inhibitors

• Dopamine Agonists

• COMT Inhibitors

• Anticholinergics


GOALS ACHIEVED

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

WNL• Patient consciousness was restored


PROBLEMS IDENTIFIED

• Use of Piracetam • Proper Treatment for Cardiac morbidity was

started late (ACE inhibitor was started on day 11th)

• Use of Doxycyclin even when weil felix test was –ve

• LFT & 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 LFT


PATIENT COUNSELLING


About the disease(Diabetes)

Signs and symptoms complications


About the disease (PD)


About Medication

About medicati

– Name and purpose

– Dose and frequency

– Medication adherence

– Possible adverse effects

– Missed dose

Avoid Medications: Haloperidol Chlorpromazine Risperidone Olanzapine Reserpine Methyldopa Metochopramide Amitryptalline


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


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


Date post:	02-Dec-2014
Category:	Health & Medicine
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LVF with HTN and T2DM and PD

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