N. Lavanya
roll 93
A 60 year old male, who is a resident of Nalgonda ,farmer by occupation
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A 60 year old male, who is a resident of Nalgonda ,farmer by occupation came with
Chief complaints
-Pedal edema since 3 months
-shortness of breath since 20 days
- decreased urine output since 15 days
History of presenting illness
The patient was apparently asymptomatic 3 months back then developed bilateral pedal edema initially extending to ankle Gradually progressed up to thighs which worsened during last 15 days.
Decreased urine output since 15 days, not associated with frequency, urgency burning micturation.
Grade 3 shortness of breath, noaggravating and relieving factors.
PAST HISTORY
Known case of hypertension since 6 months
No history of diabetes mellitus, asthma, cardiovascular disease , epilepsy, tuberculosis
no history of blood transfusions.
Personal history
Married
Farmer
Mixed diet
Sleep adequate
Bowel-Regular
Bladder-Irregular
No allergies known
Occasionally consumes alcohol
Smokes tobacco
Family history :
father is hypertensive
No history of Asthama DM TB epilepsy etc
General examination
The patient is conscious coherent cooperative
Well oriented to time place and space
Moderately built and nourished
Pallor present
Bilateral pedal odema present until ankle pitting type
Clubbing is seen
No icterus
No lymphadenopathy
Vitals
Temp:99.1°F
PR: 98
Rr: 29/ min
Bp:100/80 mm Hg.
Spo2: 84%
GRBS:124 mg
Clubbing
Pitting type pedal
Fever chart :
Systemic examination
Cardiovascular system:
-S1,S2 heard .no mumurs.
Respiratory system:
-Position of trachea central.
- Bilateral airway entry present.
-Dyspnea present
- no wheeze
Abdomen:
-Scapoid
-No tenderness
-No palpable mass
-Spleen : not palpable
-liver : not palpable.
CNS examination:
conscious coherent and cooperative
higher mental function normal
-no signs of meningeal irritation.
Provisional diagnosis
Chronic kidney disease on maintenance with hemo dialysis with anemia of chronic disease with hypertension
INVESTIGATIONS
28/11/23
HEMOGRAM
- Hemoglobin:5.4gm/dl.
-total count: 26,800
-Neutrophils- 89
-lymphocyte:5
-eosinophil:06
- monocyte :0
-Basophils:0
-PCV : 16.1
-MCV : 84.1
-MCH : 28.1
-MCHC : 33.4
-RDW -CV :22.9
-RDW-SD : 66.3
- platelet count : 1.32
Impression: Normocytic Normochromic with neutrophilic
leukocytosis and thrombocytopenia.
RENAL FUNCTION TEST
Urea : 131mg/dl
Creatinine 4.6 mg /dl
Uric acid 9.9 mg/dl
Calcium 10.1 mg/dl
Phosphorus 5.1 mg /dl
Sodium 137 meq /l
Potassium 4.1 meq / l
Chloride 102 meq/l
Abg
PH 7.46
Pco2 29.4 mmhg
Po2 165 mmHG
Hco3 20.7 mol /l
Tco2 44.9vol
O2 sat 98.8 %
O2 count 8.9vol %
HIV 1/2 Rapid : Non reactive
Anti HCV antibodies Rapid : Non reactive
HBsAg Rapid : negative
On29/11/23
HEMOGRAM
- Hemoglobin:5.4gm/dl.
-total count: 22,300
-Neutrophils- 91
-lymphocyte:4
-eosinophil:0
- monocyte :5
-Basophils:0
-PCV : 16.2
-MCV : 84.4
-MCHC : 28.3
-RDW -CV :22.1
-RDW-SD : 66.9
- platelet count : 1.52
Impression: Normocytic Normochromic with neutrophilic leukocytosis.
RENAL FUNCTION TEST
Urea 146 mg/dl
Creatinine 7.7 mg /dl
Uric acid 10.8 mg/dl
Calcium 9.9 mg/dl
Phosphorus 5.6 mg /dl
Sodium 129 meq /l
Potassium 4.7 meq / l
Chloride 89 meq/l
Abg
PH 7.74
Pco2 25.9 mmhg
Po2 46.1 mmHG
Hco3 19 mol /l
Tco2 43.3 vol
O2 sat 92.4 %
O2 count 2.4 vol %
USG report
ECG :
2d echo report
Treatment
On 28 /11/23
Patient was on salt restriction < 1.5 g / day
Patient was on fluid restriction <1.5l per day
Inj : PIPTAZ 2.25 gm iv /tid
Inj LASIX 40 mg iv /bid
Inj MEOMOL 14 mg iv sos if temp >101
Tab : ECOSPRIN 50mg H/S
Tab : OROFER once a day
Tab DOLO 650 mg every 6 hourly
Tab NODOSIS 500 mg PO /BD
Tab SHELCALT 500 mg /BD
On 29/11/23
TAB. LINOD 10mg twice a day.
Inj LASIX : 40 mg Iv twice a day
Tab : Oral NODOSIS 500 mg twice a day
Tab: Oral SHELCAL 500 mg twice a day
Inj.EPO 4000 IU ,SC once weekly
Tab : oral ECOSPRIN 75mg H/S
Inj NEOMAL : 14mg IV sos
Tab : DOLO 650 mg QID
Inj PIPTAZ : 2.25 gm I.v thirice a day.
On 30 /11/23
Treatment
Inj PIPTAZ : 2.25 gm I.v twice a day.
Inj LASIX : 40 mg Iv twice a day
Inj NEOMAL : 14mg IV sos
Tab : Oral NODOSIS 500 mg twice a day
Tab: Oral SHELCAL 50 mg twice a day
Tab : oral ECOSPRIN 50mg H/S
Tab OROFER once a day
Tab : DOLO 650 mg QID
Intermittent CPAP
Oxygen supplementation 1-2L
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