What Do These Lab Reports In A Person With Urinary Retention And Swelling In Lower Limbs Indicate?

Question : This is a 71-years old male member, who presented to the hospital with complaints of urinary retention, and bilateral lower limb edema.

History of Presenting Complaints:

This member presented to the Emergency Department on 17th August 2015, at 7:00 PM, with complaints of urinary retention, and bilateral lower limb and abdominal swelling. He also complained of increased breathlessness and cough. He was suspected of Exacerbation of Congestive Cardiac Failure, and Lower Respiratory Tract Infection. On the basis of the condition of the member, he was given verbal approval for admission and further evaluation.


Clinical Examination (At Time of Admission):
On clinical examination:
•     The bladder is distended
•     Bilateral lower limb edema

Hospitalization Course:

Day - 1

•     Patient got admitted.
•     Vitally stable.
o     Temperature: Afebrile
o     Blood Pressure: 99/50 mmHg
o     Pulse: 90 per minute
•     Tab. Lasix was kept on hold till further notice.
•     There is bilateral pedal edema
•     As per patient’s son, patient voided once after admission/

Day 2:

•     Investigations ordered: ECG, Chest X-ray, Urine analysis
•     Vitally stable.
o     Temperature: Afebrile
o     Blood Pressure: 98/50 mmHg
o     sPO2: 95-96% on RA
•     Patient voided.
•     The general condition is good with no special complaints.
•     On examination:
o     Pitting bilateral leg edema up to the thigh
o     Bilateral crepts
•     Investigations:
o     Chest X-ray: Effusion present
o     CBC: anaemia
o     LFT: deranged
o     CRP: increased
•     Diagnosed as Congestive Cardiac Failure with Lower Respiratory Tract Infection

Day 3:

•     Patient complaints of dyspnoea, productive cough (mucopurulent sputum), bilateral pedal edema
•     On clinical examination:
o     Anaemia: JVP increased
o     Pedal Edema: ++
o     Chest: Bilateral crepts, more on right side with decreased air entry
•     Investigations:
o     Chest X-ray: bilateral chest consolidation ? right side
o     Hb: 9.3
o     BNP > 1300
o     CRP: 61
o     ECHO: Ejection Fraction of 20-25%
•     Patient was transferred to ICU as he developed hypotension + oliguria + in sepsis due to lung infection.
•     Blood pressure range from 85-95 systolic
•     On IV fluids, IV Avelox for lung infection, Omnic; Aldactone, Aspirin, Plavix, Crestor for CCF; Injection Albumin

Day 4:

•     The patient is still in ICU for BP, heart rate and urine output monitoring
•     Investigations:
o     WBC: 7.23
o     Hb: 9.0
o     Platelets: 155


•     ICU Review: K/C of heart failure, BPH, CAD with Triple Vessel Disease
o     Transferred from medical war due to shortness of breath, hypotension, and oliguria.
•     O/E: Alert, conscious
o     BP: 80-90/40-50
o     HR: 75-90/min
o     SpO2: 92-95%
o     Lungs: wheeze generalized, reduced air entry lower zone
o     Urine output: 30-35 ml/hour
o     On IV drip: 50 ml/ hour normal saline
•     Laboratory:
o     Na: 125
o     Urea: 10.8
o     Creatinine: 125
•     Plan: Nebulization with Pulmicort, Ventolin and Atrovent
o     Withhold Lasix today
o     Continue Aldactone
o     Continue IV Drop NS at 50 ml/hour
o     Continue Avelox
o     Keep in ICU for close observation of BP + Lungs
•     On high protein, low fat, low cholesterol diet, with normal salt (as sodium level is low)
•     At 18:00: Catheter clamped for bladder training

Day 5:

•     Shifted to medical ward
•     Patient vitally stable
•     Intake and output recorded
•     Labs (CPC, RFT, and CRP) sent
•     Chest; Bilateral crepitations
•     Bilateral pedal edema
•     Continue same management

Day 6:

•     Patient vitally stable
•     Intake and output recorded
•     IV Lasix started stat 20 mg
•     Nebulization done
•     Foley’s Catheter removed, he passed urine.

Day 7:

•     Patient vitally stable
•     Oriented and ambulatory
•     Having bilateral pedal edema and mid edema in hands (bilaterally)
•     Voiding freely
•     Intake: 280 ml, Output: 480 ml (Negative balance: 200)
•     Investigations:
o     Hb: 9.7
o     WBC: 141
o     CRP: 43.7
o     Creatinine: 85.2
o     Urea: 8.2
o     Na: 126
o     K: 4.2
o     Calcium: 1.95
o     BNP: 1320

Day 8:

Notes not available.

Day 9:

•     Member is for discharge today

Medications:

Tab. Crestor, Tab Aspirin, Tab Plavix, Tab Carvedilo, Neb Pulmicort, Neb Ventolin + Atrovent, Tab Lasix, Injection Albumin


Our Concerns:

1- What should be the length of admission for the member?
2- What is the role of sepsis in this case? Should the sepsis ruled out?
3 - Was the decision to with-hold Lasix correct?
4- Should IV Lasix have been started as the treatment of choice?