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



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