65 YEAR OLD MALE FARMER WITH METABOLIC SYNDROME (DM, HTN, CAD-HF, CKD)

A 65-year-old male from Chityal Farmer by occupation was brought to ER with complaints of bilateral pedal edema, and shortness of breath since 15 days.

He was the first born child in family with 1 younger brother and 2 sisters.

Since childhood days he used to be very active and went to school by walking for nearly 4km.

During his 10th standard as his father passed away he stopped his studies & being the elder son he took responsibility of his family and started to work.

Married in 1980 and has three children- 2 sons and 1 daughter. He used to do farming and was living happily with his family.

His daily routine includes waking up at 5 am - goes to cattle shed & comes back at 7am - eat breakfast & goes to field at 9 to 10am - returns home at 1 to 2pm - takes rest for sometime after having lunch & again goes to field - returns home at 5 to 6 pm & sleeps at 9pm.

Since twenty years he had complaints of bilateral knee pains which were relieved by painkillers. Used NSAIDs & other ayurvedic medications.

12 years ago he felt dizzy and went to an RMP doctor where on a routine health checkup he was found to be hypertensive and was started on antihypertensives.

7 years ago his elder son expired after an electric shock at the workstation.  He took a lot of time to come out of that situation and felt very stressed during that period. After that, his daughter-in-law left the home leaving her 1-year-old daughter. Since then he used to taken care of her.

6 years ago when he went to Hyderabad to his brother in law home who is a known diabetic and has a glucometer at home. Casually he also tested his GRBS which showed above 200 mg/d and so he immediately gave FBS, PPBS in the laboratory and was diagnosed with diabetes. Consulted a local physician and was started on OHA.

5 years ago he lost his mother (due to old age).

2 years back when he went to a local hospital for a routine health checkup he was told he has some kidney problem and so shifted from OHA to insulin therapy.

Inspite of many hurdles in life he was so strong and faced them.

But it all changed 1 year back in June 2022 when he had complaints of nausea, vomiting, and shortness of breath grade 2 aggravated on exertion he went to a local doctor in Nalgonda where he was told he has a kidney problem and was referred to Hyderabad for further management. There dialysis was initiated and since then he was on maintenance hemodialysis - Initially, weekly once for two months, and from September he is on dialysis weekly twice.

Since 15 days he has complaints of bilateral pedal edema extending up to the shin of the tibia, and increased shortness of breath grade 3-4 associated with orthopnea & PND.

No history of chest pain, palpitation, or syncope

No history of fever, cold, or cough

No history of decreased urine output or dysuria

No other complaints

PAST HISTORY:

Patient is k/c/o HTN since 12 years and on  medication

K/c/o T2 DM since 6 years initially used OHA (4years) - converted to insulin in v/o renal failure (2years)

K/c/o CKD on MHD since 1 year

No h/o CAD, CVA, Asthma, TB, or Epilepsy

FAMILY HISTORY:

Mother has hypertension and diabetes

Sister has hypertension and thyroid disorder

PERSONAL HISTORY:

Mixed diet & normal appetite.

He is an Occasional alcoholic since 40 yrs

No bowel and bladder disturbances

GENERAL EXAMINATION : 

Patient was conscious, coherent & cooperative

Oriented to time, place & person

Moderately built & nourished

  

Pallor ++ 

 

Pedal edema - grade 2, bilateral, pitting 

 

No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy

Raised Jugular venous pressure 

Mid arm circumference: 27cm

 

Triceps skin fold thickness: 15mm

 

Mid arm muscle mass: MAC - (0.314 x TSF) = 27 - (0.314 x 15) = 27 - 4.71 = 22.29 cm

Abdominal circumference at the level of umbilicus: 87cm

Fat to Muscle ratio (FM ratio): 3.9

Pulse rate - normal volume, regular in rhythm,94 beats/min, normal character, no radio femoral, no radio-radial delay, all peripheral pulses were felt.

BP- 150/100 mmHg in both arms  

RR- 24 cpm, Abdomino-Thoracic breathing

SpO2- 96% on RA

GRBS- 218 mg/dl

SYSTEMIC EXAMINATION: 

CARDIOVASCULAR SYSTEM:

Inspection: 

Chest is bilaterally symmetrical 

No precordial bulge

Apex impulse visible in 6th intercostal space, lateral to the midclavicular line 

 

No visible pulsations, sinus, scars, or dilated veins.

Palpation: 

All inspection findings are confirmed 

Apex impulse - felt in 6th intercostal space,1 cm lateral to the midclavicular line 

Parasternal heave present (grade-2) 

No palpable thrills.

Auscultation: 

Mitral area - S1 and S2 heard, Pan systolic murmur radiating to the axilla

Aortic area - S1 and S2 heard ,no murmurs

Pulmonary area - S1 and S2 heard ,no murmurs

Tricuspid area - S1 and S2 heard ,Pan systolic murmur 

RESPIRATORY SYSTEM:

Inspection:

Chest is elliptical & bilaterally symmetrical

   

Trachea appears to be central

Movements appear to be equal on both sides

No scars, sinuses, or visible pulsations

Apex impulse visible in 6th intercostal space, lateral to the midclavicular line 

Palpation:

No local rise of temperature

No tenderness

All inspection findings are confirmed: Trachea is central, movements equal on both sides

Antero-posterior diameter of the chest: 19cm

Transverse diameter of the chest: 25cm

Chest circumference: 80 cms

Chest expansion: 1cm

Apex beat felt in 6th intercostal space,1 cm lateral to the midclavicular line 

Tactile vocal fremitus: equal on both sides in all areas

Percussion:

Resonant note were heard in all areas

Auscultation:

Bilateral air entry present

Normal vesicular breath sounds were heard

Fine crepts heard bilaterally in infra axillary & infra scapular areas

PER ABDOMEN:

Obese abdomen

Midline inverted umbilicus

No visible pulsations/engorged veins/scars/sinuses

Soft, non-tender, no organomegaly, no free fluid

Bowel sounds present

CENTRAL NERVOUS SYSTEM:

HMF - Intact                                   R.        L.

MOTOR SYSTEM: Power:   UL 4/5      4/5

                                                   LL  4/5      4/5

TONE - Normal.

REFLEXES - B.    T.    S.     K.    A.   P.

               R.     +2  +2.  +1.   +2.   --.  Flexion.

               L.     +2. +2.  +2.   +2.   --.  Flexion.

CRANIAL NERVES - Normal.

GAIT:

PROVISIONAL DIAGNOSIS:

Acute on Chronic LVF ? secondary to CAD

Anemia ?secondary to CKD

K/c/o CKD since 2 years on MHD since 1 year

K/c/o HTN since 12 years & DM-II since 6 years

INVESTIGATIONS:

June 2022

June 2022

January 2023

01/04/2023

USG Abdomen

Normal sized kidneys

B/L grade-II RPD

02/04/2023

21/04/2023

2D ECHO

Dilated LA/LV/RA/RV

Global hypokinesia

Severe LV dysfunction

Concentric LVH +

Severe MR+/TR with PAH +

Diastolic dysfunction +

22/04/2023

FINAL DIAGNOSIS:

Acute on Chronic LVF 

CAD - Evolved AWMI

HFrEF

Normocytic Normochromic Anemia secondary to CKD

K/c/o CKD since 2 years on MHD since 1 year

K/c/o HTN since 12 years & DM-II since 6 years