Case 30 46 female with sob

DOA 19/12/23

EXPIRED IN FEBRUARY 2025

Diagnosis

ACUTE PULMONARY EDEMA

CKD ON MAINTENANCE HEMODIALYSIS

HEART FAILURE WITH PRESERVED EJECTION FRACTION

ANEMIA OF CHRONIC DISEASE (SECONDARY TO CKD)

HTN

T2DM

Case History and Clinical Findings

PATIENT CAME WITH C/O GENERALISED BODY SWELLING SINCE 2 MONTHS

C/O SOB SINCE 20 DAYS

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN SHE DEVELOPED

SHORTNESS OF BREATH, GRADE 2 ASSOCIATED WITH GENERALISED BODY SWELLING

SINCE 20 DAYS

NO H/O CHEST PAIN, PALPITATIONS, COUGH, VOMITING, LOOSE STOOLS, PAIN ABDOMEN

BLOOD TRANSFUSION DONE ON

21/12/2023 (PRBC)

27/12/2023 (PRBC)

DIALYSIS DONE ON

21/12/2023

24/12/2023

27/12/2023

30/12/2023

02/01/2024

05/01/2024

08/01/2024

12/01/2024

15/01/2024

PAST HISTORY

K/C/O HYPERTENSION, DIABETES MELLITUS, CHRONIC KIDNEY DISEASE

N/K/C/O TB, ASTHMA,EPILEPSY,CVA,CAD

GENERAL PHYSICAL EXAMINATION

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

PALLOR IS PRESENT

B/L PEDAL OEDEMA PRESENT

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS

TEMPERATURE - AFEBRILE

PR - 98BPM

BP - 150/90 MMHG

RR - 16 CPM

SPO2 - 98% ON CPAP

CVS - S1,S2 HEARD, NO MURMURS

RS - BAE+, NVBS +

CNS - NFND

P/A - SOFT, NNON TENDER, BOWEL SOUNDS HEARD

Investigation

Hemogram

Hb -7.0 mg/dl

TLC -8900

PLT-2.08 lakh

HBsAg-RAPID 19-12-2023 08:07:PM Negative

Anti HCV Antibodies - RAPID 19-12-2023 08:07:PM Non Reactive

RFT 19-12-2023 08:07:PM

UREA 80 mg/dl

CREATININE 4.7 mg/dl

URIC ACID 3.7 mg/dl

CALCIUM 10.0 mg/dl

PHOSPHOROUS 2.4 mg/dl

SODIUM 138 mEq/L

POTASSIUM 3.5 mEq/L

CHLORIDE 99 mEq/L

CUE ALB 2+

LIVER FUNCTION TEST (LFT) 19-12-2023 08:07:PM

Total Bilurubin 0.64 mg/dl

Direct Bilurubin 0.19 mg/dl

SGOT(AST) 16 IU/L

SGPT(ALT) 10 IU/L

ALKALINE PHOSPHATE 131 IU/L

TOTAL PROTEINS 6.0 gm/dl

ALBUMIN 3.41 gm/dl

A/G RATIO 1.32

FBS 215 mg/dl

PLBS 156 mg/dl

HBA1C 6.7%

RFT 24-12-2023 03:53:PM

UREA 75 mg/dl

CREATININE 4.6 mg/dl

URIC ACID 4.0 mg/dl

CALCIUM 10.1 mg/dl

PHOSPHOROUS 2.5 mg/dl

SODIUM 137 mEq/L

POTASSIUM 2.7 mEq/L

CHLORIDE 98 mEq/L

BLOOD UREA 11-01-2024 09:51:PM 145 mg/dl

SERUM CREATININE 11-01-2024 09:51:PM 7.3 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 11-01-2024 09:51:PM

SODIUM 139 mEq/L

POTASSIUM 5.0 mEq/L

CHLORIDE 106 mEq/L

CALCIUM IONIZED 1.14 mmol/L

BLOOD UREA 12-01-2024 12:19:AM 136 mg/dl

SERUM CREATININE 12-01-2024 12:19:AM 7.4 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-01-2024 12:19:AM

SODIUM 138 mEq/L

POTASSIUM 5.6 mEq/L

CHLORIDE 103 mEq/L

CALCIUM IONIZED 1.19 mmol/L

USG ABDOMEN 20/12/2023

-LEFT MILD PLEURAL EFFUSION

-RIGHT KIDNEY GRADE 1 RPD CHANGES

-GRADE 1 FATTY LIVER

-MINIMAL INTER BOWEL FLUID NOTED

2D ECHO DONE ON 02/01/2024

-NO RWMA; MILD LVH +

-MODERATE TR WITH PAH

-MILD TO MODERATE AR/MR;MILD TO MODERATE PR

-SCLEROTIC AV. NO AS/MS

EF = 55%

-GOOD LV SYSTOLIC FUNCTION

-NO DIASTOLIC DYSFUNCTION

-MINIMAL PE+

-DIALATED RA/RV/IVC/MPA

-MILD DIALATED LA

-IVC SIZE(1.93CMS) DILATED,NON COLLAPSING

Treatment Given(Enter only Generic Name)

1. FLUID RESTRICTION <1.5L/DAY

2. SALT RESTRICTION <2G/DAY

3. INJ. LASIX 40MG IV/BD

4. TAB NODOSIS 500MG PO/OD

5. TAB NICARDIA 20MG PO/TID

6. TAB ARKAMINE 0.1MG PO/BD

7. TAB OROFER XT PO/OD

8. TAB SHELCAL CT PO/OD

9. INJ. ERYTHROPOIETIN 4000 IU SC/WEEKLY ONCE

10. INJ. IRON SUCROSE 200MG IV IN 100ML NS/IV

11. O2 INHALOR AND INTERMITTENT BIPAP SUPPORT

12. TAB CARDIVAS 3.12 MG PO/OD

Advice at Discharge

1. FLUID RESTRICTION <1.5L/DAY

2. SALT RESTRICTION <2G/DAY

3. TAB LASIX 40MG PO/BD

4. TAB NODOSIS 500MG PO/OD

5. TAB NICARDIA 20MG PO/TID

6. TAB ARKAMINE 0.1MG PO/BD

7. TAB OROFER XT PO/OD

8. TAB SHELCAL CT PO/OD

9. TAB CARDIVAS 3.12 MG PO/OD

Follow up

patient expired in february 2025