Health Quote

EMERGENCY CASE OF THE WEEK

DEPARTMENT OF CARDIOVASCULAR MEDICINE

A CASE OF MALIGNANT HYPERTENSION
(Updated 19.2.2013)
​
Patient Name: ****** Gupta aged: 33 years, Female

Diagnosis: Malignant Hypertension

Emergency Crisis: High Blood Pressure 

Patient reported to our Cardiology OPD on 24.6.2011 (1.30 PM) in a
quiet uneasy condition with her work colleague (Bank) and while
entering the clinic, near reception, she vomited and fell while her
colleague was getting the registration slip for the patient.

​
On Emergency call, patient was made lie down on chair and was managed as per the presentation.
​
​
Case Presentation

Patient while entering the reception, suddenly vomited and fell on side without any known cause or complaint. The accompanying office colleague could interpret only that she complained of severe headache since morning and just 10 minutes back, she started complaining of nausea and was brought to us.

No symptoms (except headache), no past history and no drug history could be collected as patient was lying in painful condition and was unable to tell her symptoms.

Observation & Quick Clinical Examination was the only way out to make a diagnosis and to revive the patient.

Patient had severe headache since morning with nausea and now vomiting. There was profuse sweat on her forehead and body temperature was above normal. Patient was highly sensitive to light.

B.P. was 186/124 mmHg and Pulse was 94/m, full and hard with RR of 26/m and patient was unable to interpret her symptoms due to severe headache, nausea and dizziness. There were loud Heart sounds without any added sounds.

Not wasting much time, she was prescribed ADRENALINUM 0/1 (10 Drops – STAT) on tongue at interval of 5 minutes for next 15 minutes.
Patient felt comfortable within next 15 minutes and asked for water and initiated talk with attending consultant. She easily drank 2 glasses of water and within next 5 minutes interpreted the whole story that what actually happened to her in her own words.

B.P after 10 minutes noted was 170/120 mmHg and Pulse was 90/m.

Adrenalinum 0/1 was given after 10 minutes and B.P. could be noted (after 25 minutes from start) as 156/110 mmHg and patient was feeling much comfortable and was easily talking to her colleague and attending consultant.

After talking to her, it could be found that she is suffering from HTn since last 6 years and is regularly taking Allopathic Drug for Htn but still BP sometimes shoot up like this and she feels as if she would have brain hemorrhage.

She was kept under observation for next 30 minutes and blood pressure was monitored in final on discharge as 140/96 mmHg and patient went to her car walking with ease.
​
Afterwards, she took treatment for same and was fully recovered from her HTn within 6 months and all allopathic drugs were tapered off within initial 20 days.



Link to websitepage: http://drbindras.wix.com/clc3795#!emergency-case-of-the-week/c9b1 

A Case of Dengue Hemorrhagic Fever Pleural Effusion and Acute Kidney Injury

A CASE OF DENGUE HEMORRHAGIC FEVER, PLEURAL EFFUSION AND ACUTE KIDNEY INJURY

Patient named Mr.Jaspreet Singh, aged 18 years, being declared at the verge of death in ICU of a leading Hospital of North India after fatal strike by Dengue Hemorrhagic Fever leading to uncontrolled hemorrhages and Acute Kidney Injury being put on Ventilator Support System after Pleural Effusion and Hypovolaemic Shock, knocked at the door of Homeopathy in end stage when Conventional System of Medicine failed to save a precious life.

How it feels when Phosphorus takes place of Heparin, Serum anguillae replaces Lasix, Ventilator Support System gets a substitute as Antimonium tart and Comatose is prevented by Opium. How it feels when a multi-specialty expert team Allopathic Physicians salute Master Hahnemann’s science, let’s discuss in this presentation.

How beautifully the Life of patient was saved homoeopathically in presence of Renowned Allopathic Physicians with their own consent is self explanatory theme of this case.

• D.O.A (at *** Ludhiana) :   14^th October, 2010
• Case C.R.No. (*** Ludhiana)  :   *****6677 

• D.O.A (at Dr.Bindra’s and Cardio Life Care) :   18^th October, 2010
• Case C.R.No. (at Dr.Bindra’s and Cardio Life Care)  :   1796-DB-04573/2010

  

CHIEF COMPLAINTS at Time of Admission to *** (14.10.2010)

• High grade Fever             x since last 4 days
• Chills with Body pains      x since last 4 days
• Pain in/over eyes             x since last 3 days
• Nausea                            x since last 3 days
• Rashes over Skin            x since last 3 days
• Loss of apetite                 x since last 3 days

H/O CHIEF COMPLAINTS

Patient was brought to *** Ludhiana at 11.30 pm (14.10.2010) with complaint of High grade fever and chills with severe body pains for last 3-4 days. As symptoms like High grade fever, chills, body pains, pain over eyelids and rashes over skin with Nausea pointed out the case to Dengue Fever, patient was advised admission in Emergency for next 24 hours observation and few lab investigations.

DRUG HISTORY

Since 1^st Day Of Fever to 14.10.2010

• Patient was given Paracetamol for Fever, Emset for Nausea, Ibuprofen for pains and fever as well along with few Home remedies for Fever or suspected Dengue Fever.

*** Ludhiana (14.10.2010 onwards) 

• IV Fluid Transfusion
• Analgesics and Antipyretics

Laboratory Investigations (*** Ludhiana)

14.10.2010

• Dengue Serology IgM Test : POSITIVE
• Platelet Count                     : 1,23,000 /cmm
• HgB                                     : 11.2 gm%
• Renal Function Test            : Normal Limits
• Liver Function Test             : Normal Limits

BEGINNING OF EMERGENCY CRISIS

17.10.2010

Chief Complaints:

• Decreased Urine Output (200 ml/24 hr)
• Pain in Lower Back and Loins
• Weakness and Lethargy
• Laziness
• Nausea and Vomiting

Advised CBC, RFT and ordered to shift to Nephrology Ward

18.10.2010

• Platelet Count                     : 11000 /cmm (Eleven thousand)
• HgB                                     : 8.5 gm%
• Blood Urea                          : 124 mg/dl
• Serum Creatinine                : 6.9 mg/dl

Patient was shifted to Nephrology ward after diagnosis of Acute Kidney Injury (Acute Renal Failure) and was planned to give Diuretics as Urine output was falling drastically.

18.10.2010

Chief Complaints:

• Hemorrhages from IV sites
• Hemorrhages from Oral Aphthous ulcers
• URINE OUTPUT NIL (ANURIA)
• Confusion of Mind and Semi-conscious state.

Patient was ordered immediately shifting to ICU 2 and advised SDP (Single Donor Platelets) Transfusions and Dialysis was planned after Transfusion of SDP’s.

HOMOEOPATHIC INTEREVENTION

18.10.2010 (7 pm)

Patient’s father called us up and asked to help in this crucial stage as patient’s condition was worsening by each hour and they were not in favor to carry out Dialysis on their Son.

I visited Nephrology ward and studied records of the patient and talked to the Assistant Professor of Nephrology Department about their view of prognosis in the case and his words were slightly bitter but clear that patient is very sick (almost at the verge of death) and now only God can save him but still we will try our best.

As case had worsened to very advance critical stage, I requested father of the patient to let them (CMC Doctors) transfuse SDP’s and carry out dialysis because we cannot do anything in few hours or overnight. I assured him of our best efforts to save his son, rest pray to the Nature.

Chief Complaints/Signs and Observations: (after my visit)

• Hemorrhages from IV sites and Oral Aphthous ulcers
• URINE OUTPUT NIL (ANURIA)
• Confused state of Mind and Semi-conscious state.
• Sleepiness and Stupor.
• Frightful in Sleep (weeping and screaming 1+)

 PHYSICAL EXAMINATION

• Pulse    : 78/m
• B.P       : 110/70 mmHg
• Temp.   : 101`F
• R/R       : 26/m
• CVS Exam : S1 S2 Normal, No added sounds.
• Lower Extremities pitting oedema++.
• P/A NAD. 

• Chest B/L crepts ++
• Impaired Intellect and Behavior, Confused state of mind (Pre Comatose?)

  

PRESCRIPTION:

           OPIUM CM - 1dose STAT (18.10.2010 10.30 PM)

                                                                                                                                                                    

_________________________________________________________

19.10.2010 (8.30 pm) – [PATIENT WAS SHIFTED TO ICU 2]

DIALYSIS 1 – Performed 2:30 am 19.10.2010 (4 hours)

TRANSFUSION - 3 SDP’s in last 24 hours

After almost 20 hours of OPIUM CM dose, patient was re-examined and case was evaluated again.

Although patient was out of the state of pre-comatose but condition was worsening due to hemorrhages from nose, IV sites and oral apthous ulcers. Blood Pressure was falling due to hemodynamic instability and Urine output was almost NIL.

Chief Complaints/Signs and Observations: (after my visit)

• OUT OF PRE-COMATOSE, Much active and conscious as compared to last day.
• Hemorrhages from IV sites, Nose and Oral Aphthous ulcers
• URINE OUTPUT NIL (ANURIA)
• Confused state of Mind and Semi-conscious state.
• Pain in Loins and back.
• Nausea and Vomiting.

PHYSICAL EXAMINATION

• Pulse    : 80/m
• B.P       : 100/64 mmHg
• Temp.   : 104`F
• R/R       : 24/m
• CVS Exam : S1 S2 Normal, No added sounds.
• Lower Extremities pitting oedema+++.
• P/A NAD.
• Chest B/L crepts ++

  

LAB INVESTIGATIONS

• Blood Urea (after dialyisis)  : 92mg/dl
• S.Creatinine (after dialysis) : 5.2 mg/dl
• Platelet Count                      : 27,000/cmm (AFTER 3 SDP’s)

  

PRESCRIPTION:

           PHOSPHORUS 0/1 Oral - Hourly (19.10.2010 - 9.30 PM)

After written consent by Patient’s Father, Attending Homoeopath (me), details of the Homoeopathic Medicine prescribed, finally Head of Department of Nephrology of CMC allowed Patient’s Father to visit ICU at night every hour to administer Homeopathic Medicine without any interference of the ICU staff.

_________________________________________________________ 

20.10.2010 (2.30 pm)

DIALYSIS 2 – Performed 4:30 am 20.10.2010 (6 hours)

TRANSFUSION - 2 SDP’s in last 24 hours

After almost 14 hours of repeated administration of PHOSPHORUS 0/1 orally, Hemorrhages from oral ulcers was under control but there was no improvement in IV sites and Nasal Hemorrhages.

Chief Complaints/Signs and Observations:

• Hemorrhages from IV sites, Nose
• Oral Aphthous ulcers Hemorrhages slightly under control
• URINE OUTPUT NIL (ANURIA)
• Temperature shoot up with Chill and shivering after our medicines in night which is not getting down even with high doses of Anti-pyretics. (THIS WAS A SIGN OF HOPE FOR US, BUT A ALARMING SIGN AS WELL)

PHYSICAL EXAMINATION

• Pulse    : 78/m
• B.P       : 110/70 mmHg
• Temp.   : 105.6`F
• R/R       : 22/m
• CVS Exam : S1 S2 Normal, No added sounds.
• Lower Extremities pitting oedema+++.
• P/A NAD.
• Chest B/L crepts +++

 LAB INVESTIGATIONS

• Blood Urea (after dialyisis)  : 106mg/dl
• S.Creatinine (after dialysis) : 4.9 mg/dl
• Platelet Count                      : 26,000/cmm (AFTER 2 SDP’s)

  

  PRESCRIPTION:

  CONTINUED - PHOSPHORUS 0/1 Oral - Hourly (20.10.2010 - 3.00 PM)

21.10.2010 (8.30 pm)

DIALYSIS 3 – Performed 10.30 am 21.10.2010 (4 hours)

TRANSFUSION - 2 SDP’s in last 24 hours

 After almost 50+ hours of repeated administration of PHOSPHORUS 0/1 orally, now the Hemorrhages from IV sites, Oral Ulcers and Nose were under 30-40% control and this was enough for us to continue with Phosphorus as a ray of hope had finally knocked at our door.

This % was calculated by ICU RMO as they were changing the Gauge Bandages every 30-45 minutes on last day but since last night onwards Gauge were being changed after almost 60-80 minutes and this was a big sigh of relief for them.

Chief Complaints/Signs and Observations: 

• Hemorrhages from IV sites, Nose and Oral Aphthous ulcers Hemorrhages 30-40% under control.
• URINE OUTPUT NIL (ANURIA)
• Temperature coming down after 12 hours and now there were no chills and shivering now.
• DIFFICULTY IN BREATHING  (Oxygen Mask Support Given)

PHYSICAL EXAMINATION

• Pulse    : 82/m
• B.P       : 110/70 mmHg
• Temp.   : 102`F
• R/R       : 20/m
• CVS Exam : S1 S2 Normal, No added sounds.
• Lower Extremities pitting oedema+++.
• P/A NAD.
• Chest B/L crepts +++

 LAB INVESTIGATIONS

• Blood Urea (after dialyisis)  : 82mg/dl
• S.Creatinine (after dialysis) : 4.4 mg/dl
• Platelet Count                      : 32,000/cmm (AFTER 2 SDP’s)

PRESCRIPTION:

          PHOSPHORUS 0/2 Oral - Hourly (21.10.2010 - 8.30 PM)

 PATIENT WAS SHIFTED TO VENTILATOR SUPPORT LAST NIGHT DUE TO DIFFICULTY IN BREATHING.

VENTILATOR MODE – SIMV i.e. Synchronous Intermittent Mandatory Ventilation (NON-INVASIVE, FACIAL MASK)      

After telephonic reporting by patient’s father about Ventilator Support System, Medicine administration method was shifted to Applying on Clean Skin Surface on any part of body.

                                                                                    

 22.10.2010 (3.30 pm)

 DIALYSIS 4 – Performed 4 am 22.10.2010 (6 hours)

TRANSFUSION - NO SDP in last 24 hours (For the 1^st time since last week)

After repeated administration of PHOSPHORUS 0/2 on skin surface, now the Hemorrhages from IV sites, Oral Ulcers and Nose were under 70% control and for the first time in last 7 days, there was no transfusion of SDP’s today.

This % was calculated by ICU RMO as they were changing the Gauge Bandages every 60-80 minutes on last day but since last night onwards Gauge were being changed after almost after every 2 hours or even more.

Chief Complaints/Signs and Observations:

• Hemorrhages from IV sites, Nose and Oral Aphthous ulcers Hemorrhages 70% under control.
• HEMATURIA
• URINE OUTPUT 100 ml/24 hours (ANURIA)

PHYSICAL EXAMINATION 

• Pulse    : 77/m
• B.P       : 100/70 mmHg
• Temp.   : 101`F
• R/R       : 18/m
• CVS Exam : S1 S2 Normal, No added sounds.
• Lower Extremities pitting oedema+++.
• P/A Tenderness.
• Chest B/L crepts +++

 LAB INVESTIGATIONS

• Blood Urea (after dialyisis)  : 88mg/dl
• S.Creatinine (after dialysis) : 4.7 mg/dl
• Platelet Count                      : 46,000/cmm (NO SDP’s)

PRESCRIPTION:

          PHOSPHORUS 0/2 On Skin Surface – 2 Hourly (22.10.2010 - 3.30 PM)

23.10.2010 (8.30 pm)

DIALYSIS 5 – Performed 11 am 23.10.2010 (6 hours)

TRANSFUSION - 1 SDP in last 24 hours

After repeated administration of PHOSPHORUS 0/2 – 2 hourly, now the Hemorrhages from IV sites, Oral Ulcers and Nose were almost under control.

Gauge changing frequency at Hemorrhages sites was almost reached to 6 hours or 3 times in last 24 hours.

Chief Complaints/Signs and Observations:

• Hemorrhages from IV sites, Nose and Oral Aphthous ulcers Hemorrhages almost under control.
• HEMATURIA
• URINE OUTPUT 140 ml/24 hours (ANURIA)

PHYSICAL EXAMINATION

• Pulse    : 76/m
• B.P       : 110/68 mmHg
• Temp.   : 100`F
• R/R       : 18/m
• CVS Exam : S1 S2 Normal, No added sounds.
• Lower Extremities pitting oedema+++.
• P/A Tenderness.
• Chest B/L crepts +++

 LAB INVESTIGATIONS

• Blood Urea (after dialyisis)  : 96mg/dl
• S.Creatinine (after dialysis) : 4.9 mg/dl
• Platelet Count                      : 73,000/cmm (1 SDP Transfuion)

Platelet Count raised from 46,000 to 73,000

 Now Hemorrhages were almost under control but Platelet Count was a serious matter in front of us, so re-evaluated the case and finally decided to change the prescription this time.

PRESCRIPTION:

          Crotalus horridus 30c in Liquid Dilution ON SKIN – 2 Hourly (23.10.2010 - 9.30 PM)

DIALYSIS 6 – Performed 6 am 24.10.2010 (6 hours)

TRANSFUSION - NO SDP in last 24 hours

After repeated administration of Crotalus horridus 30c Liquid dilution – 2 hourly on SKIN and without any Transfusion of SDP’s the Platelet count was higher than previous day report.

Patient was transfused Packed Cells today as Hemoglobin count was 8.2 last day.

Chief Complaints/Signs and Observations:

• Anuria + Hematuria

  

PHYSICAL EXAMINATION

• Pulse    : 76/m
• B.P       : 90/60 mmHg (Dropped down, given some Allopathic Inj. to stabilize?)
• Temp.   : 101`F
• R/R       : 20/m
• CVS Exam : S1 S2 Normal, No added sounds.
• Lower Extremities pitting oedema+++.
• P/A Tenderness.
• Chest B/L crepts +++

 LAB INVESTIGATIONS

• Platelet Count                      : 80,000/cmm (NO SDP Transfuion)

Platelet Count raised from 73,000 to 80,000 without any transfusion.

PRESCRIPTION:

          Crotalus horridus 30c in Liquid Dilution ON SKIN – 4 Hourly (24.10.2010 - 9.30 PM)

25.10.2010 to 27.10.2010

DIALYSIS 7,8,9 – Performed (6 hours)

TRANSFUSION - NO SDP     

Chief Complaints/Signs and Observations:

• Anuria + Hematuria

LAB INVESTIGATIONS

• Platelet Count 27.10.2010             : 1,10,000/cmm (NO SDP Transfuion)

Platelet Count raised from 80,000 to 1,10,000 without any transfusion in 3 days.

 PRESCRIPTION:

          Crotalus horridus 30c in Liquid Dilution ON SKIN – 4-6 Hourly (25/26/27.10.2010)

28.10.2010 (9.30 PM)

DIALYSIS 10 – Performed (4 hours)

TRANSFUSION - NO SDP     

 Chief Complaints/Signs and Observations: 

• Anuria + Hematuria

 LAB INVESTIGATIONS

• Platelet Count 28.10.2010             : 1,27,000/cmm (NO SDP Transfuion)

Platelet Count raised from 1,10,000 to 1,27,000 without any transfusion .

PRESCRIPTION:

          Crotalus horridus 30c in Liquid Dilution ON SKIN – 6 Hourly (28.10.2010)

29.10.2010 to 2.11.2010

DIALYSIS 11 to 15 – Performed (4-6 hours)

TRANSFUSION - NO SDP     

VENTILATOR MODE – SIMV i.e. Synchronous Intermittent Mandatory Ventilation (NON-INVASIVE, FACIAL MASK)      

Chief Complaints/Signs and Observations:

• Anuria + Hematuria
• Mild ECG Changes but no significative.
• Pleural Effusion

 LAB INVESTIGATIONS

Platelet Count 1.11.2010  : 1,68,000/cmm (NO SDP TRANSFUSION)  

                        2.11.2010  : 1,72,000/cmm (NO SDP Transfuion)

Platelet Count raised from 1,27,000 to 1,72,000 without any transfusion in 5 days.

As Platelet Count was Stable now and Life was out of Danger, we considered to go  ahead with a prescription that could intervene with Ventilator Support and Pleural Effusion so that Ventilator could be weaned off.

PRESCRIPTION:

          Antimonium tartaricum 0/1 ON SKIN – 2 Hourly (29.10.2010 3.30 PM)

3.11.2010 to 5.11.2010

DIALYSIS 19 to 21 – Performed (4-6 hours)

VENTILATOR MODE – SIMV i.e. Synchronous Intermittent Mandatory Ventilation (NON-INVASIVE, FACIAL MASK)      

Chief Complaints/Signs and Observations:

• Anuria + Hematuria
• Pleural Effusion

  

LAB INVESTIGATIONS 

• Renal Function Test 4.11.2010  : B.Urea : 108mg/dl

                                                     S.Creat: 2.2 mg/dl

As patient was on Antimonium tart 0/1 and X-Ray changes were quite significative and were giving a good response to our medicine, we continued with Antimonium tartaricum 0/1 and then raised to Antimonium tart 0/2 and 0/3 for next days.

PRESCRIPTION:

          Antimonium tartaricum 0/2 ON SKIN – 3 Hourly (3/4.11.2010 8.30 PM)

          Antimonium tartaricum 0/3 ON SKIN – 4 Hourly (5.11.2010    3.30 PM)

6.11.2010 (MORNING 7 AM)

Received a call from Patient’s father that Doctors of ICU have planned to Wean Off the Ventilator by today evening after X Ray and check up by the Senior Consultants.

VENTILATOR WEANED OFF ON 6.11.2010 (5.30 pm) and patient was advised to take some Oral Liquid diet by next morning.

7.11.2010

DIALYSIS 22 – Performed (6 hours)

Chief Complaints/Signs and Observations:

- Anuria + Hematuria

- Cough with Expectoration

- Thirst for Cold Drinks

- Restlessness

- Pain in Lower Abdomen

LAB INVESTIGATIONS

Renal Function Test 7.11.2010  : B.Urea : 82mg/dl

                                                     S.Creat: 1.6 mg/dl

 Now we have the patient completely in stable state and our concern was to track his kidney failure and need proper medicine for his renal inactivity. 

So finally after a long evaluation of 2 hours with reference to almost a library of books, we came to selection of Serum anguillae 6x as final resort.

  

PRESCRIPTION:

          Serum anguillae 6x Liquid Dilution Orally – 3 hourly (7.11.2010- 11.30 PM) 

PATIENT SHIFTED TO NEPHROLOGY WARD

8.11.2010 to 23.11.2010

DIALYSIS 22 to 31  – Performed (4-6 hours)

NO DIALYSIS AFTER 16.11.2010

SERUM ANGUILLAE 6x continued for these 15 days with frequent repetition for first 5 days and then ending up with TDS dosage.

Chief Complaints/Signs and Observations: (between these days)

First 3 days (NO IMPROVEMENT)

- Anuria + Hematuria

- Cough with Expectoration

- Pain in Lower Abdomen

4^th - 7^th  day

- No Blood in URINE (NO HEMATURIA)

- URINE OUTPUT : 200-350 ml/24 hr

- Profuse Perspiration in AC’s

-  Pain in Loins (Rt>Lt)

7^th - 15^th  day (WORKING KIDNEYS)

- No Blood in URINE (NO HEMATURIA)

- URINE OUTPUT : 700-1500 ml/24 hr (Increased day by day)

- Excessive Appetite

- Very Dull Pain in Loins, Mild (Rt=Lt)

Chief Consultant Nephrologist (H.O.D.) told that the kidneys are now in very healthy working condition and the patient was advised a good diet and walk for 10-15 mins daily in hospital lobby.

LAB INVESTIGATIONS

Renal Function Test 24.11.2010: B.Urea : 32mg/dl

                                                     S.Creat: 0.5 mg/dl