1601006100-long case 50 YEARS OLD MALE WITH SOB AND GENERALISED EDEMA

March15,2023

50yr old male patient came to casuality with cheif complaints:

Shortness of breath since -10days

Swelling of upper and lower limbs since-6days

Decreased urine output since - 6days

HISTORY OF PRESENT IllNESS:

-patient was apparently asymptomatic 1year back the he had SOB which is intermittent type and then he was also diagnosed with CKD 1year back

-10days back he had sudden onset of SOB which is grade IV

-orthopnea present

-paroxysmal nocturnal dyspnea present

-EDEMA of both upper and lower limbs .

Lower limb edema which is Pitting type upto thigh 

PAST HISTORY:

-he was asymptomatic 10 years ago 

-History of fall from tree then onwards he developed backache and neckpain .            

-3yrs back he had fever ,cough,loss of appetite for 2months and had been diagnosed with tuberculosis and diabetes.

-he took anti tuberculosis therapy for 6months and on oha since then.

-Seasonal SOB with wheeze (since 3 years) on and off and with CKD 1 year ago.                                                                                                        

GENERAL EXAMINATION:

patient was conscious, cooperative and oriented to time,place and person

No signs of pallor ,icterus ,cyanosis, lymphadenopathy.                                -Bilateral pitting edema is present.

            B/L pitting edema 

         Imaginary pillow.

VITALS:

TEMPERATURE: afebrile 

PULSE RATE: 102 bpm

RESPIRATORY RATE: 35cpm

BLOOD PRESSURE: 150/90 mm hg

SPO2: 97% @ room air

GRBS: 203 mg/dl (N-<140mg/DL)

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:.                             inspection:

-Shape of chest- elliptical 

-No engorged veins, scars, visible pulsation

Palpation :

-APEX BEAT @ 6TH INTERCOSTAL SPACE IN ANTERIOR AXILLARY LINE 

Auscultation:

S1 and S2  are heard 

RESPIRATORY SYSTEM: 

inspection: 

Shape-elliptical 

B/L symmetrical

Both sides moving equally with respiration.

No scars ,sinuses, engorged veins, pulsations

Palpation :

trachea -central 

expansion of chest is symmetrical

 Auscultation : bilateral air entry present 

INVESTIGATIONS:

Serology:

HCV: NON REACTIVE

RANDOM BLOOD SUGAR: 125mg/dl

RFT:.                                    RFT on 15/3/23

S.UREA: 64mg/dl.      ------>140mg/dl     

S. CREATININE: 4.3 mg/dl--->5.7mg/dl

S. Na+: 138

S. K+: 3.4

S. Cl-: 104

S. Ca+2: 0.92

-HbA1C: 6.5%

Complete urine examination:

Colour -pale 

Albumin -nil

HEMOGRAM.                   On15/3/23

Hb-12.6.           ----.           11.7

Lymphocytes -15    ---.       20 

Rbc count. 4.7.    ----.        4.4

platelet count-1lakh   ---.   1lakh

CHEST X-ray:

ECG:

ULTRASOUND:

USG CHEST: 

E/O FREE FLUID NOTED IN BILATERAL PLEURAL SPACES (RIGHT MORE THAN LEFT) .                           IMPRESSION:

BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT)                                       

LFT: 

Total bilirubin- 2.8mg/dl.    --->(N-0.2 to 1.0mg/dl)

Direct bilirubin -1.2mg/dl.   --->(N-upto0.25mg/dl).              Alt -250U/L.     --->(N-40U/L).                                            Ast-210U/L.      --->(N-40U/L)

ABG:

pH: 7.3.     

PCO2: 28.0.    Nr-(35-45mmhg)

pO2: 77.4.       

HCo3: 13.5.      Nr-(22-28)

PROVISIONAL DIAGNOSIS:

ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES)

HEART FAILURE.

WITH K/C/O DM II SINCE 3 YEARS

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

6. INJ. HUMAN ACTRAPID INSULIN SC/TID

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