53M WITH SOB AND PEDAL EDEMA
Case History and Clinical Findings
Treatment Given
C/O PEDAL EDEMA SINCE 2 MONTHS C/O SOB SINCE 3 DAYS C/O DECREASED URINE OPUTPUT SINCE 1 WEEK
HISTORY OF PRESENTING ILLNESS:
PT WAS APPARENTLY ALRIGHT 1 YEAR BACK THEN HE WAS DIAGNOSED WITH CKD AND WAS ON CONSERVATIVE MANAGMENT . PATIENT HAD DECREASED URINARY OUTPU SINCE 1 WEEK NO HESITANCY, DRIBBLING OF URINE PEDAL EDEMA SINCE 2 MONTHS, PITING TYPE UPTO KNEE SOB SINCE 3 DAYS GRADE IV, ORTHOPNEA+ NO PND , NO CHEST PAIN, PALPITATIONS
PAST HISTORY:
K/C/O DM II SINCE 7 YRS ON INSULIN
K/CO HTN 1 YEAR ON CLINIDIPINE 10MG
PERSONAL HISTORY :
DIET MIXED APPETITE DECREASED SLEEP ADEQUATE BOWEL REGULAR ADDICTIONS NONE
GENERAL PHYSICAL EXAMINATION PATIENT IS CONCIOUS COHARENAT COOPERATIVE
VITALS
PR 90 BPM
BP 130/80 MM HG
RR 17 CPM
TEMP 98.7 F
GRBS : 102 MG/DL
SPO2 99 @ RA
CVS : S1 S2 +
RS : BAE +, TRACHEA CENTRAL , NVBS HEARD, B/L BASAL CREPTS PRESENT CNS : HMF INTACT , NO NEUROLOGICAL DEFICITS
P/A : SOFT , NT.
COURSE IN THE HOSPITAL 53 YEAR OLD MALE PRESENTED WITH THE ABOVE MENTIONED COMPLAINS, PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS AND AS DIAGNOSED AS CKD STAGE V . IN VIEW OF SEVERE AZOTEMIA AND FLUID OVERLOAD PATIENT AND ATTENDERS WERE EXPLAINED NEED FOR HAEMODIALYSIS. RIGHT JUGULAR CATHETERIZATION WAS DONE AND THE PROCEDURE WAS UNEVENTFUL. PATIENT RECEIVED 4 SESSIONS OF HD DURING THE HOSPITAL STAY , 2 UNITS PRBC TRANSFUSION WAS DONE. PATIENT RECOVERED SYSMPTOMATICALLY AND DISCHAREGED IN STABLE CONDITION . FURTHER NEED FOR REGULAR HAEMODIALYSIS WAS EXPLAINED AND AV FISTULA NEED HAS BEEN EXPLAINED.
usg done on 8/10/23 E/O MILD FREE FLUID NOTED IN B/L DSPACES WITH UNDERLYING LUNG COLLAPSE IMPRESSION- B/L MILD PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE B/L GRADE II RPD CHANGES GRADE I FATTY LIVER
Diagnosis :
CKD STAGE V INITIATED ON MHD DIABETIC NEPHROPATHY HEART FAILURE WITH REDUCED EJECTION FRACTION (EF- 44%) ANAEMIA OF CHRONIC DISEASE K/C/O TYPE II DM , HTN
Treatment Given
SALT RESTRICTION <2GM/DAY FLUID RESTRICTION <1.5 LTR /DAY TAB . NICARDIA 10 MG PO TID TAB . OROFER PO OD TAB . SHELCAL P OD TAB . DOLO 650MG PO SOS TAB. NODOSIS 500 MG PO/ INJ. EPO 4000 IU S/C TWICE WEEKLY INJ. IRON SUCROSE 200MG IN 100 MLNS TWICE WEEKLY.
Advice at Discharge
REGULAR HAEMODIALYSIS SALT RESTRICTION <2GM/DAY FLUID RESTRICTION <1.5 LTR /DAY TAB. LASIX 40 MG PO/BD TAB. CARVEDILOL 3.125 PO/OD TAB . NICARDIA 10 MG PO TID TAB. ECOSPRIN AV 75/20 PO/OD TAB . OROFER PO OD TAB . SHELCAL P OD INJ. EPO 4000 IU S/C TWICE WEEKLY INJ. IRON SUCROSE 200MG IN 100 MLNS TWICE WEEKLY TAB . DOLO 650MG PO SOS TAB. NODOSIS 500 MG PO/OD
