55 Yr OLD FEMALE B/L PEDAL EDEMA, SOB, PAIN ABDOMEN SINCE 15 DAYS, DECREASED URINE OUTPUT SINCE 4 DAYS
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UNIT 2 ADMISSION
Dr.VAMSHI KRISHNA (INTERN)
Dr.PRADEEP (INTERN)
Dr.JAYANTH (INTERN)
Dr.ISMAIL (INTERN)
Dr.YAMINI (INTERN)
Dr.AMULYA (INTERN)
Dr.PRADEEP (PG 1st YEAR)
Dr. NIKITHA (PG 2nd YEAR)
Dr.SUFIYA (PG 3rd YEAR)
Dr. SATHISH (PG 3rd YEAR)
FACULTY: Dr. VIJAYALAKSHMI
case presentation:
55 year old male came to complaints of pain abdomen since 15 days,
bilateral pedal edema since 15 days
shortness of breath since 15 days
decreased urine output since 4 days
70 yr female who lives alone pt was apparently alright 15 days back then she had insidious onset of pain abdomen increases after taking rice relieves with vomitings nonprojectile, contains food particles,non foul smelling vomitings subsided after 2 days from 15 days pt also had insidious onset of B/L pedal edema till knee(pitting type) associated with shortness of breath on walking for 500 meters . no H/O ORTHOPENIA ,PND.
pt is having decreased urine output (since 4 days)
K/C/O DM2,HTN( since 10 years) on metformin 500 mg and atenolol 50 mg
N/K/C/O ASTHMA/TB/EPILEPSY/THYROID DISORDERS
no H/O fever,loose stools,chest pain, palpitations, headache
ON EXAMINATION:
Pt is concious/coherent/cooperative
VITALS
TEMPERATURE:afebrile
BP:120/80mm Hg
PR:56 bpm
RR:20 cpm
SPO2:96%
BILATERAL PITTING TYPE PEDAL EDEMA
NO pallor/icterus/cyanosis/clubbing/lymphadenopathy
SYSTEMIC EXAMINATION:
CVS: S1 S2 + , NO ADDED SOUND
CNS:NAD,NO FOCAL DEFICIT
R/S:BAE +
P/A: SOFT, NONTENDER, NO ORGANOMEGALY
INVESTIGATIONS:
2D ECHO:
severe MR,TR,mild MS ,all chambers are dilated,global akinesia of LV ,EF - 32%
DIAGNOSIS:
HFrEF with EF- 30% with CAD with PRERENAL AKI( resolving) ON CKD stage 4 SECONDARY TO DIABETIC NEPHROPATHY
TREATMENT:
1)IVF NS, RL U.0+30ml/hr
2)INJ. PAN40 MG/IV/OD
3)INJ. ZOFER 4 MG/IV/BD
4) CONTINUE ANTIHYPERTENSIVE ( ATENOLOL 50 mg)
5)GRBS 6 TH HRLY
6)INJ. HAI s/c after informing faculty
7)W/H all OHA till further orders
8) strict I/O CHARTING
9)BP/PR/RR CHARTING 4 TH HRLY
10)INJ. LASIX 40 MG/IV/OD
DAY 1
1)ORAL FLUIDS UPTO 2LIT
2)IVF NS U. O+30ml/hr
3)TAB. PAN 40 MG/OD
4)TAB. ZOFER 4MG/SOS
5)T. ECOSPRIN AV (75/20 MG) OD
6)T. OROFER XT BD
7)INJ. LASIX 40 MG/IV/BD
8)GRBS 6TH HRLY
9)inj. HAI s/c 2pm after informing
10)INJ. HUMAN MIXTARDS/C 8 IU (8:00 AM) 6IU (8:00PM)
11) strict I/O CHARTING
12)T. AMLONG 5 MG OD
13)T. CLOPITAB 75 mg OD
DAY 2
1)ORAL FLUIDS UPTO 2LIT
2)TAB. PAN 40 MG/OD
3)TAB. ZOFER 4MG/SOS
4)T. ECOSPRIN AV (75/20 MG) OD
5)T. OROFER XT BD
6)INJ. LASIX 40 MG/IV/BD
7)GRBS 6TH HRLY
8)inj. HAI s/c 2pm after informing
9)INJ. HUMAN MIXTARDS/C 6 IU (8:00 AM) 4IU (8:00PM)
10) strict I/O CHARTING
11)T. AMLONG 5 MG OD
12)T. CLOPITAB 75 mg OD
13)T.SHELCAL CT OD
DAY 3
1)ORAL FLUIDS UPTO 2LIT
2)TAB. PAN 40 MG/OD
3)TAB. ZOFER 4MG/SOS
4)T. ECOSPRIN AV (75/20 MG) OD
5)T. OROFER XT BD
6)INJ. LASIX 40 MG/IV/BD
7)GRBS 6TH HRLY
8)inj. HAI s/c 2pm after informing
9)INJ. HUMAN MIXTARDS/C 6 IU (8:00 AM) 4IU (8:00PM)
10) strict I/O CHARTING
11)T. AMLONG 5 MG OD
12)T. CLOPITAB 75 mg OD
13)T.SHELCAL CT OD
