58 yr old male patient with CKD
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19 JAN 2022
On 11th jan , A 58 yr old male patient came to casualty
CHIEF COMPLAINT :
The patient came to casualty with complaints of shortness of breath since 1week
He also have cold and cough since 5 days
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic since 1year back , he then developed shortness of breath , cough , pedal edema , decreased urine output ,
Distended abdomen , was taken to hospital and patient was diagnosed with renal failure and heart failure .
Patient was advised to undergo dialysis treatment but patient refused for it and was on conservative management .
Shortness of breath- Grade 3 relieved on sitting position ,
increased while lying ,
orthopnea - +ve
Chestpains and palpitations present
Fever , cough , cold
Sputum is mucoid , froathy , yellow white .
HISTORY OF PAST ILLNESS :
K/c/o HTN since 1year
Medication used : Clonidine
Not a case of asthma , DM , epilepsy
PERSONAL HISTORY:
Patient is married
Occupation : daily labourer
Diet : mixed
Appetite: normal
Sleep : adequate
Bowel and bladder movements: regular
No addiction : Alcoholic stopped 1yr back ( beedi 1pack per day )
No allergies
GENERAL EXAMINATION:
- Patient is conscious,coherent and cooperative
No pallor
No icterus
No lymphadenopathy
No cyanosis
No clubbing of fingers
- pedal edema subsided
VITALS:
Temperature- 98°F
Pulse rate -96 bpm
Respiration rate -16cycles per minute
Bp-140/80 mm Hg
Spo2 -96%
SYSTEMIC EXAMINATION:
CNS : no abnormality detected
CVS :
-S1, S2 are heard
Loud P2
Raised JVP.
- No murmur
RESPIRATORY SYSTEM:
MOVEMENT OF CHEST:
RIGHT LEFT
SUPRACLAVICULAR :. SYM. SYM
MAMMARY:. SYM SYM
INFRAMAMMARY :. SYM ASYM
AXILLARY:. SYM. SYM
INFRA AXILLARY :. SYM. SYM
SUPRASCAPULAR :. SYM. SYM
SCAPULAR :. SYM SYM
INFRASCAPULAR:. SYM. ASYM
ON INSPECTION :-
Chest movements: Bilaterally symmetrical
Trachea is central in position
PALPATION:-
All inspiratory findings are confirmed
Vocal fremitus decreased
Trachea is central in position
PERCUSSION:-
Stony dull heard in left mammary region
Right. Left
SUPRACLAVICULAR :. Resonant (R) R
MAMMARY:. R R
INFRAMAMMARY :. R Dullness
AXILLARY:. R R
INFRA AXILLARY :. R R
SUPRASCAPULAR :. R R
SCAPULAR :. R R
INFRASCAPULAR:. R Dullness
AUSCULTATION:-
Wheeze present
Breathe sounds : diminished on left side (mammary, infra scapular region)
Vocal resonance :decreased
SUPRACLAVICULAR :. Resonant (R) R
MAMMARY:. R R
INFRAMAMMARY :. R vocal
Resonance
decreased
AXILLARY:. R R
INFRA AXILLARY :. R R
SUPRASCAPULAR :. R R
SCAPULAR :. R R
INFRASCAPULAR:. R Dullness
ABDOMEN:
- shape of abdomen: distended
- No engorged veins, scars
- Tenderness : No
- Liver : not palpable
- Spleen : not palpable
- Bowel sounds present
PROVISIONAL DIAGNOSIS:
Chronic renal failure
Right Heart failure
Pleural effusion
Anemia of chronic disease secondary to CKD
With hypertension since 1year
Clinical images :
INVESTIGATIONS :
Fever chart :
On 14th
12 pm : 98.6 F
2 pm : 97.4 F
On 15th
12 am : 98.2 F
2 am : 96.9 F
X ray
ECG :
Ultrasound :
Hemogram
2D echo
Treatment :
On 11th
T. NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Tab ARIKAMINE
Inj. Erythropoietin
Salt water restriction
On 12th :
T. NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Tab ARIKAMINE
Inj. Erythropoietin
T.Monocef 500 mg
On 13th :
T. NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Tab ARIKAMINE
Inj. Erythropoietin
T.Monocef 500 mg
Nebulization
Monitor vitals
On 14th :
T. NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Tab ARIKAMINE
Inj. Erythropoietin
T.Monocef 500 mg
Nebulization
Monitor vitals
Syp ascoril 15ml
On 15th
T. NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Tab ARIKAMINE
Inj.monocef
On 17th
T. NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Tab ARIKAMINE
Syp ascoril 0.1 gm
