50 YEARS OLD MALE WITH SOB AND GENERALISED EDEMA

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Presenting complaints:

Patient came to casuality with the cheif complaints of sob since 10 days

Complaints of edema of upper limbs and lower limbs since 6 days

Decreased urine output since 6 days

HOPI:

Patient was apparently asymptomatic 1 year back then he had sob which is intermittent type then he was diagnosed with CKD 1 year back.

10 days back he had sudden onset of sob, which is GRADE IV, orthopnea present, pnd present

Edema of both upper and lower limbs

Lower limb edema which is pitting type upto thigh 

Asymptomatic 10 years ago. History of fall from tree. Developed low backache and neck pain then 3 years back fever, cough loss of appetite for 2 months diagnosed with tuberculosis and diabetes. ATT for 6 months and on OHA since then

Seasonal SOB with wheeze (since 3 years) on and off and with CKD 1 year ago. Increased sob and edema since 10 days decreased urine output for w days

                           Imaginary pillow 

Past history:

K/c/o TB 3 years back (ATT )

K/c/o DM II 3 years (using Metformin 500mg TID)

K/c/o CKD

GENERAL PHYSICAL EXAMINATION:

Patient is conscious coherent and cooperative

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy

VITALS:

TEMPERATURE: afebrile 

PULSE RATE: 102 bpm

RESPIRATORY RATE: 35cpm

BLOOD PRESSURE: 150/90 mm hg

SPO2: 97% @ room air

GRBS: 203 mg/dl

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1 AND S2 HEARD.

APEX BEAT @ 6TH INTERCOSTAL SPACE IN ANTERIOR AXILLARY LINE 

P2 NOT PALPABLE 

JVP MILD RAISE

RESPIRATORY SYSTEM:

BILATERAL AIR ENTRY PRESENT 

CENTRAL NERVOUS SYSTEM:

HIGHER MOTOR FUNCTIONS NORMAL

PER ABDOMEN:

SOFT NON TENDER

INVESTIGATIONS:

Serology:

HCV: NON REACTIVE

RANDOM BLOOD SUGAR: 125mg/dl

RFT:

S.UREA: 64mg/dl

S. CREATININE: 4.3 mg/dl

S. Na+: 138

S. K+: 3.4

S. Cl-: 104

S. Ca+2: 0.92

HbA1C: 6.5%

CUE:

HEMOGRAM:

CHEST X RAY:

ELECTROCARDIOGRAPHY:

2DECHOCARDIOGRAPHY:

MODERATE MR+: MODERATE TR+ WITH PAH: TRIVIAL ECCENTRIC TR+

GLOBAL HYPOKINETIC, NO AS/MS. SCLEROTIC

MODERATE LV DYSFUNCTION+

DIASTOLIC DYSFUNCTION PRESENT

ULTRASOUND:

USG CHEST: 

E/O FREE FLUID NOTED IN BILATERAL PLEURAL SPACES (RIGHT MORE THAN LEFT) WITH UNDERLYING COLLAPSE

NO E/O ANY CONSOLIDATORY CHANGES IN BILATERAL LUNG FIELDS

IMPRESSION:

BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT) WITH UNDERLYING COLLAPSE.

USG ABDOMEN AND PELVIS:

MILD TO MODERATE ASCITES

RAISED ECHOGENECITY OF BILATERAL KIDNEYS

HEMOGRAM:

LIVER FUNCTION TEST:

RENAL FUNCTION TEST:

UREA: 64

CREATININE: 4.3

Na+ 138

K+ 3.4

Cl-  104

Ca+2.   104

Spot urine protein: 34

Spot urine creatinine: 14.8

Spot urine protein creatinine ratio: 2.29

ABG:

pH: 7.3

PCO2: 28.0

pO2: 77.4

HCo3: 13.5

Sat O2: 94.7

URINARY ELECTROLYTES:

Urine Na+ 204

K+ 5.1

Cl- 135

FASTING BLOOD SUGAR: 93mg/dl

POST LUNCH BLOOD SUGAR: 152mg/dl

RFT ON 15/03/2023

S. UREA: 140mg/dl

S. CREATININE:5.7 mg/dl

S. Na+:141

S. K+:3.0

S. Cl-:0.90

HEMOGRAM:

PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF:45%) SECONDARY TO CAD

WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES/NSAID INDUCED)

WITH ALCOHOLIC HEPATITIS (DIRECT BILIRUBIN RAISE)

WITH K/C/O DM II SINCE 3 YEARS

WITH OLD PULMONARY KOCHS(3 YEARS AGO)

WITH ? COPD(? EMPHYSEMA/ALLERGIC BRONCHITIS)

WITH BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT)

TREATMENT:

1. FLUID RESTRICTION LESS THAN 1.5 LITRES/DAY

2. SALT RESTRICTION LESS THAN 1.2GM/DAY

3. INJ. LASIX 40 MG IV/BD

4. TAB. MET XL 25 MG PO/OD

5. TAB. CINOD 5 MG PO/OD(IF SBP MORE THAN 110 MM HG)

6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)

7. INJ. PAN 40 MG IV/OD

8. INJ. ZOFER 4 MG IV/SOS

9. STRICT I/O CHARTING

10. VITALS MONITORING 

11. TAB. ECOSPRIN AV 75/10 MG PO/HS