A 45 YR OLD FEMALE WITH SHORTNESS OF BREATH ,PEDAL EDEMA &ABDOMINAL DISTENSION
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A 45 year old female came to casualty presented with
CHIEF COMPLAINTS :
Shortness of breath since 3 days
Abdominal distension since 7 days
Pedal edema since 3 days
Tingling and numbness of hand since 2 days
Anuria since 1 day
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic days back then she developed shortness of breath which is insidious in onset aggravated on standing and relieved on lying down.
Her abdominal distension relieved after passing 400ml of urine through foleys Catheterization.
PAST HISTORY:
Patient was daily labourer 15 years back
H/o Hysterectomy 15 years back
-She worked for 3 years after hysterectomy then she developed lower back pain which relieved on medication given by local doctor.
-She consulted different hospitals in 10 years and used different medicines to relieve the lower back pain
ON. 16/3 /22 :
PATIENT WAS ADMITTED UNDER ORTHO FOR LOW BACK ACHE &B/L HIP PAIN
&WAS DIAGNOSED WITH OA B/L HIP .
LBA SECONDARY TO ?SPONDYLOARTHROPATHY
ON 22/3/22 :
INTRA ARTICULAR INJECTION OF LA WAS GIVEN IN RIGHT
On 24/3/22:
Ultrasound Abdomen & pelvis done as a part of surgical profile she was diagnosed with CKD (GRADE 3 RPD ) secondary to NSAID Abuse
-DENOVO DM since hospital admission
Then patient was referred to General medicine I/V/O CKD (GRADE 3)
- H/O HYPERTENSION SINCE 2 YEARS and on Tab.CLINIDIPINE 5MG PO/OD
INVESTIGATIONS:
On 19/3/22
TREATMENT :At Discharge on 28/3/22
1)GRBS ACC TO 7 PROFILE
INJ HAI 6 UNITS ......6 UNITS......6 UNITS
INJ. NPH 4UNITS ......X........... UNITS
2)T. NODOSIS 500 MG PO/TID X 7 DAYS
3)T.ULTRACET 1/2TAB QID X 7 DAYS
4)T. CLINIDIPINE 5 MG PO OD X 7 DAŸS
5)T.LASIX 20MG PO BD X 7 DAYS
6)T.PAN 40MG PO OD X7 DAYS
7)FLUID RESTRICTION <1.5LT / DAY
8)DIABETIC DIET
9)SALT RESTRICTION <2.5gm
GENERAL EXAMINATION:
Patient is conscious coherent cooperative well oriented to time place and person
No pallor Ictrus, cyanosis, clubbing, lymphoadenopathy
VITALS
TEMPERATURE - 98.5F
PULSE RATE - 102BPM
BLOOD PRESSURE - 100/80MM OF HG
RESPIRATORY RATE -
SPO2 -96 % AT ROOM AIR
GRBS-119mg/dl
SYSTEMIC EXAMINATION -
PER ABDOMEN : SOFT , TENDERNESS OVER UMBILICAL ,HYPOGATSRIC , RT < LUMBAR AND INGUINAL QUADRANTS AND
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BAE +
BILATERAL AIR ENTRY PRESENT
CENTRAL NERVOUS SYSTEM : NAD
PROVISIONAL DIAGNOSIS :
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS WITH B/L SI JOINT DEGENERATION
INVESTIGATIONS:
Ecg on 5/4/22
PROVISIONAL DIAGNOSIS :
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS WITH B/L SI JOINT DEGENERATION
INVESTIGATIONS:
Ecg on 5/4/22
USG
TREATMENT 5/4/22
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.OROFER XT PO/OD
3)TAB.SHELCAL -CT PO/OD
4)TAB.BIO -D3
5)TAB.HYDRALAZINE 12.5 MG PO/BD
6)INJ.KCL 2AMP IN 100 ML NS IV @4HOURS
7)TAB.ALDACTONE 25MG PO/OD
8)INJ.PAN 40 MG IV OD
9)INJ.ZOFER 4MG IV BD
10)SYP.POTCHLOR 10ML IN GLASS OF WATER
11)TAB.ULTRACET 1/2 TAB QID
TREATMENT on 6/4/22
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.OROFER XT PO/OD
3)TAB.SHELCAL -CT PO/OD
4)TAB.BIO -D3
5)TAB.HYDRALAZINE 12.5 MG PO/BD
6)INJ.KCL 2AMP IN 100 ML NS IV @4HOURS
7)TAB.ALDACTONE 25MG PO/OD
8)INJ.PAN 40 MG IV OD
9)INJ.ZOFER 4MG IV BD
10)SYP.POTCHLOR 10ML IN GLASS OF WATER
11)TAB.ULTRACET 1/2 TAB QID
SOAP NOTES:
AMC
7/4/22,
S:
1.Shortness of breath
2.Abdominal distension
3.Pedal edema
4.Tingling and numbness of hand
O:
Patient is conscious,cohorent and cooperative
Temp:98 F
BP:100/60 mm Hg
PR:82bpm
Spo2:99%
PER ABDOMEN : SOFT , TENDERNESS OVER UMBILICAL ,HYPOGATSRIC , RT < LUMBAR AND INGUINAL QUADRANTS
CVS : S1 AND S2 HEARD , NO MURMURS
RS: BAE +
BILATERAL AIR ENTRY PRESENT
CNS: NAD
A:
CHRONIC RENAL FAILURE WITH OSTEOPOROSIS WITH B/L SI JOINT DEGENERATION
P:
1)TAB.NODOSIS 500 MG PO/BD
2)TAB.OROFER XT PO/OD
3)TAB.SHELCAL -CT PO/OD
4)TAB.BIO -D3
5)TAB.HYDRALAZINE 12.5 MG PO/BD
6)TAB.ALDACTONE 25MG PO/OD
7)INJ.PAN 40 MG IV OD
8)INJ.ZOFER 4MG IV BD
9)SYP.POTCHLOR 10ML IN GLASS OF WATER
10)TAB.ULTRACET 1/2 TAB QID
