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

Case presentation
on left ventricular
failure with
Parkinson's
disease and type 2
DM with
hypertension
Presented by : Abhimanyu parashar
5th Pharm.D
roll no. 11

 IP no. : 223050
 UNIT : medicine 1
 AGE : 70 yrs
 SEX : Female
Thursday, September
05, 2013
2

Reasons for admission :
c/o :
 Generalized weakness x 2 days
 Inability to move x 2 days
Thursday, September
05, 2013
3

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
Thursday, September
05, 2013
4

 Pallor +
 No cyanosis , no clubbing
 CNS : cranial nerves normal
 P/A : soft and non tender
 Power :
 Tone :
Thursday, September
05, 2013
5
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 :
Thursday, September 05,
2013
6
RIGHT LEFT
B +++ ++
T ++ ++
S ++ ++
K +++ ++
A +++ ++
Plantar increased Normal

2013
7

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 .
Thursday, September
05, 2013
8

Thursday, September
05, 2013
9
Allergies FHx SHx
NKA NS NS

Personal history
 DIET : veg
 APPETITE : good
 SLEEP : undisturbed
 BOWEL and BLADDER : normal and regular
2013
10

PROVISIONAL DIAGNOSIS
 TYPE 2 DM with TRANSIENT ISCHEMIC
ATTACK
2013
11

DAY NOTES :
Thursday, September
05, 2013
12

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
2013
13

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 muscles
ADV : treatment as per chart , Hb ,TC , DC ,
RBS , Urea , electrolytes
Thursday, September
05, 2013
14

LAB REPORTS :
2013
15

Thursday, September
05, 2013
16
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%
Electrolytes
Na 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 analysis
Pus cells 2-4
Epithelial cells 1-2
IMP : microcytic hypo chromic
anemia with thrombocytopenia

TREATMENT
Thursday, September
05, 2013
17
DRUGS DOSE ROUTE FREEQUENCY
Inj. Actrapid 6-6-6 units SC 1-1-1
Tab. atorvastatin 40 mg PO 0-0-1
Tab. 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
Thursday, September
05, 2013
18

Thursday, September
05, 2013
19
LFT
AST 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)
Biochemistry
RBS 216 mg/dl
FBS 93 mg/dl
PLT 98000 cells/cumm
Lipid profile
HDL 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)

 IgM dengue :
NS 1 Ag : negative
IgM anti dengue : not detected
 Widal test : negative
 QBC-MP : negative
2013
20

TREATMENT
Tab. Atorvastatin 40 mg PO 0-0-1
Tab. aspirin and
clopidogrel
150 mg PO 0-1-0
Inj.trineurosol .H 1 cc IV 1-0-0
2013
21

DAY 3
 BP : 140/90 mm Hg
 PULSE : 82 BPM
 O/E :
 CVS/RS – NAD
 ADV : 2-D ECHO , Carotid doppler, Optho
opinion
2013
22

 Ophthalmology opinion :
IMP : no evidence of diabetic nephropathy
2013
23
Normal fundus

TREATMENT
Tab. aspirin and
clopidogrel
150 mg PO 0-1-0
Inj. Trineurosol.H 1 cc IV 1-0-0
2013
24

DAY 4
 BP : 140/80 mm Hg
 PULSE : 82 BPM
 RS/CVS : NAD
2013
25

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
2013
26

 Motor system : B/L plantar extension
 Reflex :
 ADV : CT scan , ECG , shift to emergency
ward , ABG , U/C , SE
2013
27
Right Left
Upper limb Decreased Present
Lower limb Absent Decreased

2013
28
Prothrombin time
Control 13.5 sec
Patient 30.2 sec
Ratio 2.22
Index 44.7
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
ALT 104
ALP 560
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

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)
2013
29

TREATMENT
2013
30
Tab. aspirin and clopidogrel 150 mg PO 0-1-0
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
2013
31

 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 +
2013
32

 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
2013
33

2013
34

TREATMENT
2013
35
T.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 --
2013
36

 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
2013
37

2013
38
CXR - PA view showing NORMAL and CARDIAC
HYPERTROPHY

TREATMENT
2013
39
Tab. Piracetam 400 mg PO Q8H
tab. Doxycyclin 100 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
2013
40

 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
2013
41

Thursday, September
05, 2013
42
1 2 3 4 5 6
Eyes
Does not
open
eyes
Opens
eyes in
response
to
painful
stimuli
Opens
eyes in
response
to voice
Opens
eyes
spontane
ously
N/A N/A
Verbal
Makes
no
sounds
Incompr
ehensible
sounds
Utters
inapprop
riate
words
Confuse
d,
disorient
ed
Oriented,
converses
normally
N/A
Motor
Makes
no
moveme
nts
Extensio
n to
painful
stimuli
Abnorm
al 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
2013
43
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)
2013
44
CSF analysis report
0.1 ml clear fluid
Cell count : 3 cells/cumm
Cell type : a few lymphocytes
Non 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
2013
45
electrolytes
Na 128 mmols/L
K 3.6 mmols/L
Cl 103 mmols/L

TREATMENT
2013
46

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 +
2013
47

 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
2013
48

TREATMENT
2013
49
Tab. aspirin and
clopidogrel
150 mg PO 0-1-0

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
2013
50

 POWER : 4/5
 Cog-wheel rigidity : +
 GCS : 9/15
 B/L pupil : 4 mm and reactive
 B/L plantar : flexion
 ADV : 2D-ECHO
2013
51

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)
2013
52

2013
53

TREATMENT
2013
54

DAY 10
 BP: 120/80 , 140/70 mmHg
 PULSE : 90 BPM
 FCBG : 91 mg/dl
 Pre lunch : 169 mg/dl
 O/E : patient is feeling better , conscious ,
responds well to commands can be
shifted to ward
2013
55

 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
2013
56

TREATMENT
2013
57
Inj. Actrapid 6-6-6
units
SC 1-1-1
Tab. Piracetam 400 mg PO Q8H
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
 Bed sore : +
 ADV : wound care and CST
2013
58

TREATMENT
2013
59
Tab. aspirin and
clopidogrel
150 mg PO 0-1-0
Tab. Ramipril 2.5 mg PO 1-0-0
Cap. Cobadex PO 0-1-0
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
2013
60

TREATMENT
2013
61
Inj. Actrapid 6-6-6
units
SC 1-1-1
Tab. Ramipril 2.5 mg PO 1-0-0
Cap. Cobadex PO 0-1-0
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 +
 ADV : CST
2013
62

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
2013
63

2013
64
Drugs D R F 1 2 3 4 5 6 7 8 9 1
0
1
1
1
2
1
3
1
4
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

2013
65
Drugs D R F 1 2 3 4 5 6 7 8 9 1
0
1
1
1
2
1
3
1
4
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 12-0-16
units
SC + +
T. rasagiline 0.5 mg Po 0-1-0 +
Tab.
pramipraxol
e
0.25 mg po 1-0-1 +

PHARMACEUTICAL CARE
PLAN (SOAP)
2013
66

SUBJECTIVE EVIDENCE
2013
67
Diabetes Parkinson's disease
•Generalized weakness •Inability to move around
•Reduced power
•Stupor present
•Mask like face

OBJECTIVE EVIDENCE
2013
68
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
2013
69

GOALS OF TREATMENT
2013
70

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
2013
71

2013
72
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
 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
2013
73

For CHF
 Minimize or prevent acute CHF
exacerbations
 Slow progression of CHF
 Increase survival
2013
74

For PARKINSONS DISEASE
 Improve motor function
 Maintain ability to complete daily
activities independently
 Improve non-motor symptoms
 Maintain quality of life
2013
75

2013
76
TREATMENT OPTIONS
For 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
2013
77

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
2013
78

MONITORING PARAMETERS
2013
79
 Disease related
1. Blood pressure
2. Blood glucose
3. HbA1C
4. ECG
5. Cardiac enzymes
6. Electrolytes
7. Motor symptoms

2013
80
 Drug related
 For insulin :
Monitor hypoglycemic symptoms
Monitor for lipid-dystrophy
• For ramipril :
Monitor serum potassium levels
Monitor 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
2013
81

About the disease(hypertension)
2013
82

2013
83
About the disease(Diabetes)
Signs and symptoms complications

2013
84
About the disease(heart failure)

2013
85
About the disease (PD)

About medication
 Name and purpose
 Dose and frequency
 Medication adherence
 Possible adverse effects
 Missed dose
2013
86

2013
87

About life style modification
2013
88
 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

2013
89
DASH diet

2013
90
Fat 20–35% of total caloric intake
Saturated fat < 7% of total calories
<200 mg/day of dietary cholesterol
Two 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

Thursday,
September
05, 2013
91
THANK YOU

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

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