Case history - prefinal
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DOA:- 15/12/2021
A 57 year old female patient presented to the OPD with chief complaints of decreased urinary output since 3 days , with bilateral pedal edema since 3 days and shortness of breath grade II-III since one day and fever not associated with chills and rigors
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 years back then she had low back pain which was radiating to groin. Then she went to local hospital diagnosed as renal caliculi and kidney dysfunction on investigation. From then she was on medication.
Decreased urine output since 3days
Shortness of breath with grade II-III since 1day
Cough with sputum
And fever not associated with chills and rigors
PAST HISTORY:
No similar complaints in the past
MEDICAL HISTORY:
Not a know case of diabetes, hypertension, tuberculosis, epilepsy, asthma.
FAMILY HISTORY:
No relevant family history
PERSONAL HISTORY:
-Mixed diet
-REDUCED APPETITE
-Adequate sleep
-Regular bowel movements
-micturition:- patient has decreased urinary output
-Patient has no history of any habits
TREATMENT HISTORY:
On medication for renal calculi
Not allergic to any known drugs
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent and co-operative
Well oriented to time and place
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal edema - present
Vitals:
Temperature- afebrile
Pulse rate- 89 beats per minute
Respiratory rate- 22 breaths per minute
B.P- 110/70 mm hg
SpO2- 90% at room air
SYSTEMIC EXAMINATION
Cardiovascular system:
Chest wall is bilaterally symmetrical
S1 and S2 are heard. No murmurs are heard
Respiratory system:
BAE +ve
Breath sounds- decreased breath sounds in right
Vesicular breath sounds are normal
Dyspnoea: present
Wheezing: present
Right side fine crepts present
Central nervous system:
Patient was conscious, coherent and cooperative
Speech was normal
No slurred speech
No meningeal irritation signs
No abnormality detected
GAIT:- Normal
INVESTIGATIONS
X-RAY:
Usg report :
ECG:
PLEURAL TAP was done
PROVISIONAL DIAGNOSIS:
CKD with right sided pleural effusion
TREATMENT:
1.Pleural tap
2. Head and elevation up to 30°
3. O2 supplementation if SpO2 is less than 90%.
4. Fluid restriction < 1 litre per day
5. Salt restriction < 2.4 G per day
6.Inj. Augmentin 500 mg/ IV/ OD
6. Tab. Azithromycin 500 mg/ OD
7. Inj. Lasix 40 mg IV/ BD
8. Tab
9. Tab shelcal 500 mg audi
10. Tab orofer-xT /OD
11. Inj. Erythropoietin 4000 IU s/c weekly once
12.Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13.Syrup. Ascoryl 10ml /TD
14. Monitor vitals hourly
15. Strict I/O Charting
17/12/21
1.Pleural tap
2. Head and elevation up to 30°
3. O2 supplementation if SpO2 is less than 90%.
4. Fluid restriction < 1 litre per day
5. Salt restriction < 2.4 G per day
6.Inj. Augmentin 500 mg/ IV/ OD( D3)
7.Tab. Azithromycin 500 mg/ OD (D3)
8. Inj. Lasix 40 mg IV/ BD
9. Tab shelcal 500 mg audi
10. Tab orofer-xT /OD
11. Inj. Erythropoietin 4000 IU s/c weekly once
12.Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13.Syrup. Ascoryl 10ml /TD
18/12/21
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5.Inj .pipatz 2.25gm iv bd
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8. Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj Iron sucrose 1Amp in 100 ml us during dialysis
12.Syrup. Ascoryl 10ml /TID
13.Neb with salbutamol thrice daily
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5.inj piptaz 2.24gm iv/bd
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8. Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
20/12/21
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5. D3 inj piptaz 2.25 gm/ IV/ BD
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8.Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11.Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
14. SYP LACTULOSE 10ML PO/BD
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