Acute Shortness of Breath in a 50-Year-Old Female Patient

Introduction

A female 50 year-old patient was admitted to the emergency department after experiencing acute shortness of breath. The symptoms that she presented with were noted to had begun two days early before she was brought to the hospital. The patient will be called DC for confidentiality purposes. Her symptoms got and she had had such signs six months ago with COPD and thus needed hospitalization. The patient uses BiPAP ventilator support at night when she is sleeping and she even asked for the same while she was in the emergency department as she was having shortness of breath and needing to sleep. DC denied having experienced fever, cough, or any kind of wheezing. Besides, she denied experiencing chest pain, palpitations, abdominal pains, distension, nausea, vomiting, or diarrhea as well as producing sputum. At the rest, the patient has trouble in breathing. She is also forgetful and has mild fatigue. She feels chilled and needs blankets. She has increased urinary frequency, incontinence besides having swollen lower extremities that get worse in the course of her illness.

Patient History

Looking at her family history, it is noted that there are cases of significant heart conditions, high blood pressure, high lipid levels as well as hypothyroidism, diabetes, and vascular conditions. She is currently under fluticasone-vilanterol 100-25 mcg that she inhales on a daily basis. She is also under other medications such as hydralazine that she takes 50 mg by mouth three times in a day. She is taking hydrochlorothiazide 25 mg orally on a daily basis. She inhales albuterol ipratropium at a time interval of four hours. DC has also been using levothyroxine 175 mcg orally daily and metformin 500 mg orally two times a day, 5 mg oral nebivolol daily, 81 mg oral aspirin daily and clopidogrel 75 mg orally on a daily basis. She is also under isosorbide and rosuvastatin both orally in dosages of 60 mg and 40 mg daily respectively. Lastly, she takes vitamin D3 1000 units orally on a daily basis too.

Physical Examination

Her physical examination indicates a temperature of 95 F. Her hear rate is at 76 bpm while the respiratory rate is at 25, BP 106/52, BMI 40 and oxygen saturation is 90% of the intensive care unit room air. She is extremely obese and she appears to be acute ill. When a HEENT analysis was conducted, she is noted to have a normocephalic and atraumatic head, her mouth had moist mucous membranes. Eyes examination revealed normal conjunctiva and normal EOM. Pupils were equally sized; they were round and effectively reactive to light. She lacked scleral icterus besides having bilateral periorbital edema. The Neck had a supple, she lacked JVD and there was no surgical scarring on the neck. Her throat was also moist and flagrant.

Cardiovascular

The patient underwent a cardiovascular examination and she had a normal heart rate. The heart rhythm was also regular while the hear had a normal sound with zero murmur. The four extremities of the hear had strong pulses while there was a 2+ pitting edema in the lower bilateral extremities. Normal sinus rhythm was reported from the ECG and the results were associated with non-particular ST changes in small leads. Voltage in leads I, III, aVL, and aVF were also noted to had undergone a decrease. BNP was carried out to evaluate fluid load as well as possible cases of congestive heart failure in the patient. Echocardiogram was used to evaluate the ejection fraction of the left ventricle as well as the function of the right ventricle. The echocardiogram also tested for pulmonary artery pressure alongside the functioning of the valves, pericardial effusion as well as for the hypokinetic area. BNP was noted to be 187. Since the patient was obese, the low value might have been false as she had an increased surface area. Besides, her adipose tissues have BNP receptors and these might have exaggerated the correct BNP value. From the repeated echocardiogram examination, the systolic function of the left ventricle was found to be normal. However, the cavity of the left ventricle was found to be borderline dilated. Pericardial found collection was posteriorly, laterally but not apically, also, subtle and early hemodynamic effect of the pericardial fluid was reported from the right heart compartments through collapse of the right ventricle and the right atrium as well as delayed expansion of the right ventricle to the occurrence of late diastole. Ejection fraction was estimated to range between 66% to 70%. Aortic valve was also noted to be abnormal in structure thus contributed to sclerosis. Apart from the aortic valve, the mitral valve was also noted to be abnormal in its structure.

Small annular calcification of the mitral valve was also reported from the echocardiogram examination that also reported bilateral thickening as well as trace of regurgitation of the mitral valve. The initial and confirmatory evaluations determined the patient to be hemodynamically stable with a pericardial effusion. DC had a cardiac dysfunction that was diastolic in nature. This indicated by the ejection fraction of 66%-70%. Besides, pericardial effusion of the posterior section was also noted and further supported the diagnosis. DC was also preload dependent as she showed signs of hypotension. She needed crystalloid fluid resuscitation that was effectively balanced against the effect of the heightened intravascular capacity on the congestive heart failure as well as fluid overload that was noted on DC. Replacement of thyroid hormone was used to reduce hypotension. Vasopressor agents were also used in the maintenance of the perfusion of vital organs as it targeted the arterial pressure of more than 65 mm Hg as was required by the patient. Fluid bolus was also administered that improved the blood pressure and use of norepinephrine was ceased. Also, serial echocardiogram were acquired in the quest to ensure DC was protected from tamponade physiology. CK was also increased because of hypothyroidism that was compounded with chronic renal disease.

Renal

CMP was also carried out to determine the electrolyte balance as well as examine the renal function and determine whether there was any problem with the kidney. The procedure was also targeted ay examining the arterial blood gas as a way of determining the PO2 for hypoxia and any serious acid-base imbalance. From the CMP examination, creatinine elevation was shown to be above baseline as it rose from 1.07 to 1.82. This was indicative of chances that DC had suffered from acute injury EGFR was also noted to be at 28 and was consistent with chronic disease of the renal system. Calcium levels were increased to a remarkable figure of 10.2 and were corrected to 9.8 mg/dL when corrected for albumin levels. Negligible transaminitis was also present from the enzyme tests that were carried out such as the alkaline phosphatase, AST, and ALT measurements. These were associated with liver congestion because of capacity overload. Initial blood gas of the arteries had the measurements such as pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6. Oxygen saturation was 90% relative to the surrounding room air and this was an indicator of respiratory alkalosis associated with hypoxic respiratory characteristics. Levels of creatinine kinase were high as well as serial increased levels of troponin 1. The creatinine value was an indication of chronic renal failure as well as being an indication of acute injury.

Influenza test were negative for both influenza A and B confirmatory evaluation was carried put whereby testing was undertaken to include TSH as well as free T4. TSH was 112.342 while free T4 was 0.58L. These levels were indicative of severe primary hypothyroidism. The baseline creatinine level of the patient from the analysis was close to 1.08 as per her medical records. In the emergency department, her creatinine levels were 1.8. This was caused by hypothyroidism that resulted in fluid retention due to thyroid hormone that enhanced excretion of free water as well as the reduced function of the lymphatic system that returns fluid to the ventricular circulation. We attempted aggressive diuresis to counter the condition and the result was an increased creatinine levels that was better upon repeated evaluation. Her new baseline creatinine was thus 1.6. She presented with a general change in her fluid status as she had 10 litres by the 7th day if her stay in the intensive care unit.

Respiratory

Initial evaluation was carried out to determine the cause of the dyspnea. The evaluation was inclusive of CBC that was being carried out to elucidate whether there was an infectious or anaemic source that contributed to the dyspnea. The patient also underwent a chest X-ray. From the procedure, various findings were made. First, it was noted that she had a bibasilar airspace condition that was a possible representation of alveolar edema. Also cardiomegaly was noted from the X-ray alongside protuberant interstitial patterns and mild bilateral pleural effusions. Radiographic changes of congestive failure were also noted associated with bilateral pleural effusions more on the left relative to the right side of the chest. The following day, the patient still experienced shortness of breath as the situation saw no improvement. She was experiencing more difficulty in arousing during conversations and when she was being examined. Further elucidation of her etiology was thus needed and DC’s husband provided us with a brief history of the patient which gave the revelation of a poor compliant of the patient in taking her medications as she claimed to not see the reason of taking her medications. CT scan of the chest was undertaken again.

Repeated test of the arterial blood gas on BiPAP ventilation indicated PH of 7.397, PCO2 of 35.3 and PO2 of 72.4. HCO3 was at 21.2 while the oxygen saturation was still at 90% on 2 L supplemental oxygen. On the other hand, the CT chest scan evaluated the left hemithorax, and more specifically the retrocardiac area. The patient presented with worsening metabolic acidosis that was accompanied with airway protection. The patient was immediately intubated to manage the situation. The airway protection was very risk following the fact that she not only had a large tongue but also a short neck and extremely obese. 1- Litre normal saline bolus was used since her heart was preload dependent secondary to pericardial effusion that DC experienced. The patient was also put under norepinephrine at a low dose for the benefits of acting as a vasopressor support. Ketamine was also started at a low dose as a sympathomimetic medication and is beneficial due to its distinctive feature of not causing hypotension like other sedatives. For sedation, propofol was used. DC was also ventilated with AC mode ventilation of the following parameters; tidal volume of 6 and flow of 70, initial fio2 100 %, rate 26/min and PEEP of 8.

Part 2

Cases of chronic kidney disease (CKD) have been on the rise over the past few years. It is currently the 16th leading cause of life loss across the globe (Coresh et al., 2007). The condition is typically identified via routine screening of the serum chemistry profile as well as studies of urine. Some of the symptoms that are experienced by patients suffering from CKD are inclusive of fatigue, poor appetite, nausea, vomiting, metallic taste, unintentional weight loss, pruritus, changes in mental status, dyspnea, or peripheral edema, most of which DC presented with (Chen et al., 2019). The condition involves the occurrence of an abnormality in either structure or the function of the kidney that lasts for more than a quarter of a year. The abnormalities can usually be inclusive of glomerular filtration rate of less than 60mL/min/1,73m2 or the presence of albumin in urine, abnormalities in the sediments of urine, disorders of the renal tube or history of a patient undergoing kidney transplantation (Levey et al., 2015). Repeated assessments are usually important in distinguishing CKD from acute kidney injury in cases where the duration of kidney disease is not well known (Chen et al., 2019). Besides, evaluation of the etiology of the disease is usually guided by the clinical history of the patient in question as well as physical examination alongside urinary findings.

To manage the condition, screening is important in its early detection as most patients report to be asymptomatic.

The National Kidney Foundation has developed a kidney profile. The profile includes measurements of not only serum creatinine but also estimation of the glomerular filtration rate and urine ACR (Chen et al., 2019). Screening should approach in a risk-based strategy. Besides, the procedure is considered in patients that present with clinical risk factors such as autoimmune disorders, obesity, and recurrent urinary tract infections, kidney stones, as well as lowered kidney mass (Plantinga et al., 2008). Other risk factors that should be examined for are inclusive of sociodemographic factors that increase the risk of an individual suffering from CKD. These factors are inclusive of race, low education, and low education (Chen et al., 2019).

CKD could have been managed in the clinical case. The management of the disease is dependent on other factors and thus depends on the management of other associated diseases. The first approach to the management of CKD as in the case study would involve reduction of the risk of cardiovascular disease. Notably, the prevalence of cardiovascular diseases has been noted to be more with people with CKD relative to patients without CKD. This is indicative of a link between the two conditions. A 5% Medicare sample that involved adults indicated that 65% of the adults that were aged 66 years and above had CKD and had associations with worse cardiovascular outcomes (Chen et al., 2019). Besides, the occurrence of CKD was linked to less than 2-year survival in patients that also had coronary heart disease amongst other serious heart conditions such as acute myocardial infarction, heart failure, or atrial fibrillation (Chen et al., 2019). Reduction of CKD is thus one of the most significant components of the management of CKD. In the hospital setting, it is important that patients who are aged 50 years and above that have CKD to be managed with a reduced dose of statin and low-density lipoprotein cholesterol levels (Chen et al., 2019). The eighth Joint National Committee as well as the Kidney Disease Improving Global Outcomes recommends attainment of systolic as well as diastolic blood pressures that are below 140 mm Hg and 90 mm Hg in that order (Levin et al., 2013). Besides, the programs further makes recommendations of systolic and diastolic pressures of 130 mm Hg and 80 mm Hg for adults with ACR of 30 mg/24 hours.

Another impact approach to the management of CKD is the management of hypertension (Chen et al., 2019). Particular agents should be applied in the treatment of hypertension in patients with CKD. One of the most important factors to monitor is the severity of albuminuria (Matsushita et al., 2015). Besides, it is recommend that angiotensin converting enzyme inhibitors or angiotensin II receptor blockers be used in the blockade of renin-angiotensin-aldosterone system in adults that are suffering from diabetes (Chen et al., 2019). Also, dual therapy of ACE-I and an ARB have been noted to be avoided since they have linked risks of causing hyperkalaemia thus acute kidney injury in patients. In patients that are suffering from albuminuria, aldosterone receptor antagonists can be given consideration as well as in patients suffering from resistant hypertension, or heart failure associated with a reduction ejection fraction such as DC who was the patient in the discussed case study (Matsushita et al., 2015).

Apart from managing hypertension and cardiovascular diseases, it is also important to manage diabetes mellitus as an approach to the management of CKD (Bilo et al., 2015). For instance, studies have reported that the progression of CKD can be delayed through glycaemic control. It is recommended that haemoglobin A1c of approximately 7% should be aimed at (Chen et al., 2019). Dose adjustments in oral hypoglycaemic agents are also crucial to the management of diabetes mellitus and CKD in the end. Dose reduction is necessary in drugs that are metabolized by the liver or for those that are incompletely excreted by the kidney such as metformin and dipeptide peptidase 4 (Bilo et al., 2015). Specific medication classes can be considered. An example is the SGLT-2 inhibitors for patients experiencing elevated albuminuria (Chen et al., 2019). The Canagliflozin and Renal Events in Diabetes that makes demonstrations of CKD in patients with type 2 diabetes have established nephropathy clinical evaluation trial (Chen et al., 2019). The CKD is normally in stage G2-G3/A3. Lower risks have been reported for patients that use canagliflozin or ACE-1 or ARB therapy. Patients using these medications have been reported to present with cardiovascular benefits that are extensive to the patients with CKD and reduced levels of albuminuria (Chen et al., 2019).

Patients with CKD are advised to avoid nephrotoxins (Chen et al., 2019). This is greatly advised majorly for the patients that are under ACE-1 and ARB. Patients with CKD are also required to observe various adjustments in drug dosing. Some of these drugs that would require dose reduction are inclusive of antibiotics, anticoagulants that are direct oral, oral hypoglycaemic agents, insulin, gabapentin, pregabalin, opiates as well as chemotherapeutic agents(Chen et al., 2019). These drugs can cause adverse effects in CKD patients if their doses are not significantly reduced and monitored. Apart from these, dietary management has also been discussed as an essential move in the reduction of the progression of CKD (Chen et al., 2019). Besides, in the clinical practice, it is important to monitor established CKD as well as monitoring the treatment complications. In worse situations, kidney replacement therapy can be considered as well as kidney transplant (Chen et al., 2019). This is usually because of the presence of symptoms and not on the basis of the level of glomerular filtration rate alone. Kidney replacement therapy has been considered as the optimal therapy for CKD (Chen et al., 2019). The management practices for CKD can be applied in practice for patients that are suffering from CKD like DC.

References

• Chen, T. K., Knicely, D. H., & Grams, M. E. (2019). Chronic Kidney Disease Diagnosis and Management: A Review. JAMA, 322(13), 1294–1304. https://doi.org/10.1001/jama.2019.14745
• Coresh, J., Selvin, E., Stevens, L. A., Manzi, J., Kusek, J. W., Eggers, P., ... & Levey, A. S. (2007). Prevalence of chronic kidney disease in the United States. Jama, 298(17), 2038-2047.
• Bilo, H., Coentrão, L., Couchoud, C., Covic, A., De Sutter, J., ... & Van Biesen, W. (2015). Clinical practice guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR< 45 mL/min). Nephrology Dialysis Transplantation, 30(suppl_2), ii1-ii142.
• Levey, A. S., Becker, C., & Inker, L. A. (2015). Glomerular filtration rate and albuminuria for detection and staging of acute and chronic kidney disease in adults: a systematic review. Jama, 313(8), 837-846.
• Levin, A., Stevens, P. E., Bilous, R. W., Coresh, J., De Francisco, A. L., De Jong, P. E., ... & Winearls, C. G. (2013). Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney international supplements, 3(1), 1-150.
• Matsushita, K., Coresh, J., Sang, Y., Chalmers, J., Fox, C., Guallar, E., ... & CKD Prognosis Consortium. (2015). Estimated glomerular filtration rate and albuminuria for prediction of cardiovascular outcomes: a collaborative meta-analysis of individual participant data. The lancet Diabetes & endocrinology, 3(7), 514-525.
• Plantinga, L. C., Boulware, L. E., Coresh, J., Stevens, L. A., Miller, E. R., Saran, R., ... & Powe, N. R. (2008). Patient awareness of chronic kidney disease: trends and predictors. Archives of internal medicine, 168(20), 2268-2275.

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