55 YR OLD MALE WITH SOB AND SWELLINGS OF BOTH LOWER LIMBS

202413871 islavath hanma
CHIEF COMPLAINTS:
SWELLING OF BOTH LOWER LIMBS SINCE 3 MONTHS.
DIFFICULTY IN BREATHING SINCE ONE MONTH.
HISTORY OF PRESENT ILLNESS:
-PATIENT WAS APPARENTLY NORMAL 3-4 MONTHS BACK.
-HE THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS-PITTING TYPE EXTENDING UPTO
THE KNEE-NOT RELIEVED ON LYING DOWN ASSOCIATED WITH PAIN AND TENDERNESS.
-HE VISITED A HOSPITAL AND WAS TOLD TO HAVE CKD AND PUT ON MEDICAL
MANAGEMENT.USED MEDICATION FOR 1 MONTH AND STOPPED.
-C/O DIIFICULTY IN BREATHING SINCE ONE MONTH-INITIALLY GRADE 2(MMRC) NOW
PROGRESSED TO GRADE 3-RELIEVED ON TAKING REST.
-C/O DECREASED URINARY OUTPUT SINCE 1 WEEK.
-C/O DECREASED APPETITE,CONSTIPATION.
NO C/O FEVER,NAUSEA,VOMITINGS,CHEST PAIN,PND.
-C/O CAD-CABG DONE 8 YEARS BACK.
-K/C/O DM TYPE 2 SINCE 5 YEARS.
-K/C/O HTN SINCE 1 YEAR USING MEDICATION.
-NOT A K/C/O TB,EPILEPSY,CVA,BRONCHIAL ASTHMA,THYROID DISORDERS.
TREATMENT HISTORY:
NO SIGNIFICANT HISTORY.
PERSONAL HISTORY:
MARRIED
OCCUPATION-HOTEL WORKER
APPETITE- LOST
DIET- MIXED
BOWELS- CONSTIPATION
MICTURITION- ABNORMAL:DECREASED SINCE 5 DAYS
KNOWN ALLERGIES- NO
HABITS-
a)ALCOHOL: STOPPED 2 MONTHS BACK.
b)TOBACCO- SMOKING: STOPPED 2 MONTHS BACK.
GENERAL EXAMINATION:
PT IS CONCIOUS, COHERENT, COOPERATIVE
PEDAL EDEMA+++
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPADENOPATHY
TEMP- AFEBRILE
PR- 108 BPM
RR- 24CPM
BP- 140/70MMHG
GRBS: 147 MG%
CVS- S1 S2 HEARD
RS- DECREASED BS IN RIGHT SIDE MAMMARY AREA,IAA,ISA.
CNS- NAD
P/A- SOFT, NON TENDER BOWEL SOUNDS +
CNS : NFND
INVESTIGATION
CBP HB TC N L E M B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL- HIV HBSAG HCV
NameValueNameValueLIVER FUNCTION TEST (LFT) 26-03-2024 04:07:PM Total Bilurubin0.64
mg/dlDirect Bilurubin0.19 mg/dlSGOT(AST)13 IU/LSGPT(ALT)17 IU/LALKALINE
PHOSPHATASE198 IU/LTOTAL PROTEINS5.2 gm/dlALBUMIN2.84 gm/dlA/G RATIO1.20RFT 26-
03-2024 04:07:PM UREA91 mg/dlCREATININE3.4 mg/dlURIC ACID10.1 mmol/LCALCIUM10.0
mg/dlPHOSPHOROUS3.5 mg/dlSODIUM142 mmol/LPOTASSIUM5.0 mmol/L.CHLORIDE105
mmol/LAnti HCV Antibodies - RAPID26-03-2024 04:07:PMNon Reactive HBsAg-RAPID26-03-2024
04:07:PMNegative COMPLETE URINE EXAMINATION (CUE) 26-03-2024 04:07:PM COLOURPale
yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++SUGAR+BILE
SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS2-4RED BLOOD
CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNil
ULTRASOUND (26/03/2024):
FINDINGS:
-E/O MODERATE FREE FLUID NOTED IN THE RIGHT AND LEFT PLEURAL SPACES.
-EDEMATOUS CHANGES NOTED IN THE ANTERIOR ABDOMINAL WALL.
IMPRESSION:
-BILATERAL PLEURAL EFFUSION.
-ANTERIOR ABDOMINAL WALL EDEMA.
-MILD ASCITES.
-BILATERAL GRADE 1 RPD CHANGES.
2-D ECHO (27/03/2024):
-MILD MR+ / MILD AR+ / TR+ WITH PAH. EF 20%
-DILATED CARDIAC CHAMBERS.
-GLOBAL HYPOKINESIA OF LV.
-SEVERE LV SYSTOLIC DYSFUNCTION.
-GRADE 2 DIASTOLIC DYSFUNCTION.
-MILD PERICARDIAL EFFUSION.
DIAGNOSIS
CHRONIC KIDNEY DISEASE-STAGE 4
WITH TYPE 2 DM
WITH CAD
WITH HFrEF (EF-20%)
S/P: CABG 8 YEARS BACK
TREATMENT GIVEN
1. FLUID RESTRICTION LESS THAN 1 LITRE/DAY
2. SALT RESTRICTION LESS THAN 2-3 GM/DAY
3. TAB.NODOSIS 500 MG PO/OD
4. TAB.SHELCAL-CT PO/OD
5. INJ.HUMAN ACTRAPID INSULIN SC/TID (BEFORE MEALS ACCORDING TO GRBS)
6. TAB.AUGMENTIN 625 MG PO/BD
7. TAB.PAN 40 MG PO/OD
8. GRBS 7TH HOURLY PROFILE.
9. TAB.MET-XL 25 MG PO/OD
10. TAB.DAPAGLIFOZIN 10 MG PO/OD
11. TAB.DYTOR 100 MG PO/BD
ADVICE AT DISCHARGE
1. FLUID RESTRICTION LESSTHAN 1 LITRE/DAY
2. SALT RESTRICTION LESS THAN 2-3 GM/DAY
3. TAB.NODOSIS 500 MG PO/OD
4. TAB.SHELCAL-CT PO/OD
5. INJ.HUMAN ACTRAPID INSULIN SC/TID 6U 6U 6U
6. TAB.AUGMENTIN 625 MG PO/BD FOR 4 DAYS
7. TAB.PAN 40 MG PO/OD
8. TAB.MET-XL 25 MG PO/OD
9. TAB.DAPAGLIFOZIN 10 MG PO/OD
10. TAB.DYTOR 100 MG PO/BD






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