Case 44 Doa 23/12/23 Dod 29/12/23 64 male with sob and decreased urine output since 10 days

Diagnosis

ACUTE PULMONARY EDEMA ( RESOLVING)

HEART FAILURE WITH REDUCED EJECTION FRACTION ( EF: 41 %)

CKD STAGE III A (EGFR- 56 ML/MIN)

ANEMIA ( MCHC) SECONDARY TO CKD

TINEA CORPORIS

MODERATE LV DYSFUNCTION

TYPE 2 DIABETES MELLITUS AND HYPERTENSION

Case History and Clinical Findings

PATIENT CAME WITH C/O GENERALISED BODY SWELLING SINCE 10 DAYS

C/O SHORTNESS OF BREATH SINCE 10 DAYS

DECREASED URINE OUTPUT SINCE 1 WEEK

ANURIA SINCE 8 HOURS

PATIENT WAS APPARENTLY SYMPTOMATIC 10 DAYS BACK, THEN DEVELOPED SHORTNESS

OF BREATH, WHICH IS INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE , GRADE IV

MMRC, ASSOCIATED WITH ORTHOPNEA, NO PND. GENERALISED BODY SWELLING SINCE 10

DAYS, STARTED FROM PEDAL EDEMA, PROGRESSED TO ABDOMINAL DISTENSION AND

BOTH UPPER LIMBS WITH FACIAL PUFFINESS. OEDEMA PITTING IN TYPE.

NO H/O CHEST PAIN, PALPITATIONS, NO DIURNAL VARIATION, NO H/O VOMITINGS, LOOSE

STOOLS

H/O PIGMENTED LESIONS ON HANDS AND FEET

PAST HISTORY:

K/C/O HTN SINCE 1 YEAR, USED TAB. OLMEZEST BETA 2020/50 , DM SINCE 4 YEARS , TAB.

GLIMI M1 ON IRREGULAR MEDICATION.

N/K/C/O THYROID DISORDERS , BRONCHIAL ASTHMA, SEIZURE DISORDERS

PERSONAL HISTORY

MIXED DIET

APPETITE -NORMAL

BOWEL -REGULAR

MICTURITION -NORMAL

GENERAL EXAMINATIONPT IS CONSCIOUS, COHERENT, COOPERATIVE, WELL ORIENTED

TO TIME, PLACE, PERSONMODERATELY BUILT AND NOURISHED

VITALS

BP : 110/90 MM HG

PR :120 BPM

RR: 38 CPM

TEMP: AFEBRILE

GRBS:295 MG %

SPO2: 74 % , 100 AT 3 L O2

NO PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY,

EDEMA PRESENT

SYSTEMIC EXAMINATION

CVS S1 AND S2 +

RS NVBS HEARD, BAE +

P/A - SOFT,NON TENDER

CNS EXAMINATION

NFND

Investigation

LIVER FUNCTION TEST (LFT) 24-12-2023 12:43:AM

Total Bilurubin 2.88 mg/dl 1-0 mg/dl

Direct Bilurubin 1.14 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 16 IU/L 35-0 IU/L

SGPT(ALT) 12 IU/L 45-0 IU/L

ALKALINE PHOSPHATE 210 IU/L 119-56 IU/L

TOTAL PROTEINS 5.7 gm/dl 8.3-6.4 gm/dl

ALBUMIN 2.71 gm/dl 4.6-3.2 gm/dl

FBS 156 mg/dl

Plbs 178 mg/dl

Hba1c 7.2%

A/G RATIO 0.91

COMPLETE URINE EXAMINATION (CUE) 24-12-2023 12:43:AM

COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN

NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-6EPITHELIAL CELLS 2-4RED

BLOOD CELLS 3-4CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

ABG 24-12-2023 08:58:AMPH 7.44PCO2 24.9PO2 135HCO3 16.8St.HCO3 19.7BEB -5.7BEecf -

6.5TCO2 34.5O2 Sat 98.5O2 Count 14.7

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 24-12-2023

11:18:PMSODIUM 133 mEq/L 145-136 mEq/LPOTASSIUM 3.4 mEq/L 5.1-3.5 mEq/LCHLORIDE 102

mEq/L 98-107 mEq/LCALCIUM IONIZED 1.12 mmol/L mmol/L

BLOOD UREA 25-12-2023 06:55:AM

106 mg/dl 50-17 mg/dl

SERUM CREATININE 25-12-2023

06:55:AM 4.6 mg/dl 1.3-0.8 mg/dl

ABG 26-12-2023 12:05:AM

PH 7.44PCO2 26.9PO2 237HCO3 18.4St.HCO3 20.8BEB -4.3BEecf -4.9TCO2 38.1O2 Sat 99.2O2

Count 13.9

RFT 29-12-2023 12:24:AM

UREA 89 mg/dl 50-17 mg/dl

CREATININE 1.9 mg/dl 1.3-0.8 mg/dl

URIC ACID 9.6 mg/dl 7.2-3.5 mg/dl

CALCIUM 9.8 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 4.0 mg/dl 4.5-2.5 mg/dl

SODIUM 134 mEq/L 145-136 mEq/L

POTASSIUM 4.0 mEq/L 5.1-3.5 mEq/L

CHLORIDE 101 mEq/L 98-107 mEq/L

USG WAS DONE ON 24/12/23 :

LEFT GRADE 1 RPD CHANGES, RIGHT GRADE II RPD CHANGES, GROSS ASCITES, LEFT

RENAL CORTICAL CYST, LEFT MILD PLEURAL EFFUSION WITH UNDERLYING

2D ECHO WAS DONE ON 26/12/23

GLOBAL HYPOKINETIC, MODERATE TO SEVERE MR, MAC(+), MODERATE SEVERE AR(+),

SEVERE TR (+)WITH MODERATE PAH.( ECCENTRIC PR +), PARADOXICAL IVS,

CALCIFICATION AV, THICKENED AV, EF + 41%, RVSP 45 +10= 55 MM HG, MODERATE LV

DYSFUNCTION (+), NO DIASTOLIC DYSFUNCTION , MINIMAL PE (+) AND PLEURAL EFFUSION

(+), IVC SIZE (2.10 CM) ( DILATED, NON COLLAPSIBLE), ALL CHAMBERS DILATED.

PSYCHIATRY REFERRAL WAS DONE ON 27/12/23 I/V/O ALTERED SENSORIUM, ADVISED: PT

AND ATTENDER PSYCHOEDUCATED AND TO WATCH FOR SIGNS OF DELIRIUM.

SURGERY REFERRAL WAS DONE ON 26/12/23 I/V/O SCROTAL SWELLING, PARAPHIMOSIS

SINCE 1 WEEK. ADVISED: REPOSITIONING OF FORESKIN, SCROTAL SUPPORT WITH

ELEVATION OF SCROTUM.

DERMATOLOGY REFERRAL WAS DONE ON 27/12/23: I/V/O DISCHARGE FROM THE RIGHT

FOOT.

DIAGNOSED AS TINEA CORPORIS, ? PRURIGO NODULARIS, INTERTRIGO

ADVISED:

1) LULIFIN CREAM L/A BD X 2 WEEKS M-N (LEGS)

2)CLOTRIMAZOLE CREAM L/A BD X 2 WEEKS (TOES) AND WEBSPACES

3)LIQUID PARAFFIN L/A BD X 2 WEEKS M-N (BODY)

4)FUDIC CREAM L/A BD X 1 WEEK M-N ( RAW AREAS)

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1 L/DAY

SALT RESTRICTION <1.2 G/DAY

INJ. MONOCEF 1 GM IV BD

INJ. PAN 40 MG IV/OD

TAB. CARVEDILOL 3.125 PO/OD

TAB. ECOSPIRIN GOLD 75+75+20 PO/OD X-X- 9 PM

TAB. THIAMINE 100 MG PO/BD

TAB. NODOSIS 500 MG PO /BD

SYP CREMAFFIN PLUS 10 ML PO TID

GRBS 7 POINT PROFILE

LULIFIN CREAM L/A BD

COTRIMOXAZOLE 1% CREAM L/A FOR TOES AND WEB SPACES

LIQUID PARAFFIN L/A BD

SYP POTKLOR 10 ML IN GLASS OF WATER PO/TID

INJ. IRON SUCROSE 100 MG IV/OD IN 100 ML NS

TAB. TENELIGLIPTIN 40 MG PO OD AT 2 PM

INJ HUMAN ACTRAPID INSULIN ACCORDING TO GRBS 8AM -X- 8PM

TAB. LASIX 40 MG / PO /BD

INJ. CLEXANE 0.4 ML/SC/OD X 3 DAYS

NEOSPORIN POWDER OVER THE BED SORE

FUDIC CREAM L/A BD X 1 WEEK

Advice at Discharge

TAB. TAXIM 200 MG PO OD X 5 DAYS

TAB. PAN 40 MG PO OD X 5 DAYS

TAB. CARVEDILOL 3.125 MG PO/OD

TAB. ECOSPIRIN GOLD 75+ 75 +20 PO/OD X-X-9 PM

TAB. THIAMINE 100 MG PO/BD X 15 DAYS

TAB. NODOSIS 500 MG PO/BD X 1 MONTH

TAB. TENELIGLIPTIN 40 MG PO OD

INJ HAI SC 4U TID 1-1-1

TAB.DYTOR 20 MG PO BD

TAB OROFER XT PO OD 1 MONTH

SYP CREMAFFIN PLUS 10 ML PO TID

LULIFIN CREAM L/A BD X 2 WEEKS M-N (LEGS)

CLOTRIMAZOLE CREAM L/A BD X 2 WEEKS (TOES) AND WEBSPACES

LIQUID PARAFFIN L/A BD X 2 WEEKS M-N (BODY)

FUDIC CREAM L/A BD X 1 WEEK M-N ( RAW AREAS)

Follow Up in february 2025

Patient had no fresh complaints

Fbs 120 mg/dl

Plbs 130 mg/dl

Hba1c 6.2%