50 year old male with SOB and Edema

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Presenting complaints:

Patient came to casuality with the cheif complaints of sob since 10 days

Complaints of edema of upper limbs and lower limbs since 6 days

Decreased urine output since 6 days

HOPI:

Patient was apparently asymptomatic 1 year back then he had sob which is intermittent type then he was diagnosed with CKD 1 year back.

10 days back he had sudden onset of sob, which is GRADE IV, orthopnea present, PND associated.

Edema of both upper and lower limbs

Past history:

History of fall from tree10 years ago. Developed low backache and neck pain then 3 years back fever, cough loss of appetite for 2 months diagnosed with tuberculosis and diabetes. ATT for 6 months and on OHA since then

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

K/c/o TB 3 years back (ATT )

K/c/o DM II 3 years (using Metformin 500mg TID)

K/c/o CKD

GENERAL PHYSICAL EXAMINATION:

Patient is conscious coherent and cooperative

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy

        

           

            

        

VITALS:

TEMPERATURE: afebrile 

PULSE RATE: 102 bpm

RESPIRATORY RATE: 35cpm

BLOOD PRESSURE: 150/90 mm hg

SPO2: 97% @ room air

GRBS: 203 mg/dl

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1 AND S2 HEARD.

APEX BEAT @ 6TH INTERCOSTAL SPACE IN ANTERIOR AXILLARY LINE 

P2 NOT PALPABLE 

JVP MILD RAISE

RESPIRATORY SYSTEM:

BILATERAL AIR ENTRY PRESENT 

INSPECTION AND PALPATION:

ASSYMETEICAL EXPANSION OF LUNG ON ONE SIDE ,

FAINT BREATH SOUNDS 

PERCUSSION: DULLNESS OVER EFFUSION AREA 

CHEST X RAY : HOMOGENOUS OPACIFICAFION MONISCUS SHAPE MARGIN WITH BLUNTING OF COSTOPHRENIC ANGLE . 

CENTRAL NERVOUS SYSTEM:

HIGHER MOTOR FUNCTIONS NORMAL

PER ABDOMEN:

SOFT NON Tender

RANDOM BLOOD SUGAR: 125mg/dl

           

              

RFT:

S.UREA: 64mg/dl

S. CREATININE: 4.3 mg/dl

S. Na+: 138

S. K+: 3.4

S. Cl-: 104

S. Ca+2: 0.92

HbA1C: 6.5%

2DECHOCARDIOGRAPHY:

MODERATE MR+: MODERATE TR 

MODERATE LV DYSFUNCTION+

DIASTOLIC DYSFUNCTION PRESENT

ULTRASOUND:

USG CHEST: 

E/O FREE FLUID NOTED IN BILATERAL PLEURAL SPACES LEFT MORE THAN RIGHT  WITH UNDERLYING COLLAPSE

NO E/O ANY CONSOLIDATORY CHANGES IN BILATERAL LUNG FIELDS

IMPRESSION:

BILATERAL PLEURAL EFFUSION (LEFT MORE THAN RIGHT)WITH UNDERLYING COLLAPSE.

USG ABDOMEN AND PELVIS:

MILD TO MODERATE ASCITES

RAISED ECHOGENECITY OF BILATERAL KIDNEYS

RENAL FUNCTION TEST:

UREA: 64

CREATININE: 4.3

Na+ 138

K+ 3.4

Cl-  104

Ca+2.   104

Spot urine protein: 34

Spot urine creatinine: 14.8

Spot urine protein creatinine ratio: 2.29

pH: 7.3

PCO2: 28.0

pO2: 77.4

HCo3: 13.5

Sat O2: 94.7

URINARY ELECTROLYTES:

Urine Na+ 204

K+ 5.1

Cl- 135

FASTING BLOOD SUGAR: 93mg/dl

POST LUNCH BLOOD SUGAR: 152mg/dl

RFT ON 15/03/2023

S. UREA: 140mg/dl

S. CREATININE:5.7 mg/dl

S. Na+:141

S. K+:3.0

S. Cl-:0.90

PROVISIONAL DIAGNOSIS:

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

WITH K/C/O DM II SINCE 3 YEARS

WITH OLD PULMONARY KOCHS(3 YEARS AGO)

WITH BILATERAL PLEURAL EFFUSION (LEFT MORE THAN RIGHT ) 

Heart failure with mid range ejection fraction 

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

5. TAB. CINOD 5 MG PO/OD(IF SBP MORE THAN 110 MM HG)

6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)

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 AV 75/10 MG PO/