56/M with CKD
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Here is a case I have seen.
INTERNS
juveria
Swarna
Nikhil
Manivarma
Divya
PGs
Dr. HAREEN (SR)
Dr. Praneeth Y3
Dr. Vaishnavi Y2
Dr. Vinay Y1
56 year old male, stopped working 1 year back, came with chief complaints of shortness of breath since 3month.
Pedal Edema since 3months
Decrease in urine output since 3 months.
HOPI: patient was apparently asymptomatic 9 months back. He developed shortness of breath 3months back,initially it was present on walking for some distance, now is present even on lying down (grade 2 progressed to grade 4) .
Pedal edema: since 3months, which ascended to abdominal distension, and then to facial puffiness.
Decrease in urine output is present since 3 months.
No history of palpitations, chest pain, fever with chills and rigor, cough, burning micturition.
Past history: k/c/o CKD on MHD since 1 month 30 days.
k/c/o DM since 1year, on medication (insulin)
K/c/o HTN since 1 year on medication.(nicardia 20 mg).
No h/o TB/ epilepsy/ asthma/thyroid disorder/coronary artery disease.
No history of any surgeries in the past.
Family history: no significant family history
Personal history:
Diet- mixed,
Appetite - decreased,
Sleep-decreased,
Decrease urine output,
Smoker since 20 years,
Takes alcohol occasionally.
Not allergic to any food/medication.
On examination : patient is thin built and moderately nourished.
Patient is conscious,coherent and is restless.
Vitals:
Pedal Edema is present
No pallor/ icterus/ clubbing/ cyanosis/ lymphadenopathy
BP: 120/70mmhg
PR: 100bpm
RR: 26cpm
Temp:afebrile to touch
SPo2 : 97% @RA
Systemic examination:
CVS - S1, S2 heard, no murmurs.
RS- bilateral airway entry present, decreased airway entry in b/l ISA, no added sounds.
Per abdomen- soft, non tender.
Investigations:
ECG
ON 7th feb2020
On 10/2/21
Diagnosis : CHRONIC RENAL FAILURE
Treatment : DAY 1
Salt and fluid restriction diet.
1.INJ.LASIX 40mg IV BD .
2.INJ.MONOCEF 1 g | IV | BD.
3. Tab. Pan 40 mg | PO| OD.
4.INJ. HAI S|C acc to GRBS.
5.INJ.ZOFER 4mg | IV| .
6..neb with IPRAVENT 8th hourly .
BUDECORT 12 th hourly
7.TAB.OROFER XT |PO|OD
8.TAB.SHELCAL 500 mg PO OD
9.TAB.NICARDIA 10 mg PO BD. (If SBP >110mmhg )
10.neb with SALBUTAMOL 4 STAT.
Day 2: Salt and fluid restriction diet.
1.INJ.LASIX 40mg IV BD .
2.INJ.MONOCEF 1 g | IV | BD.
3. Tab. Pan 40 mg | PO| OD.
4.INJ. HAI S|C acc to GRBS.
5.INJ.ZOFER 4mg | IV| .
6..neb with IPRAVENT 8th hourly .
BUDECORT 12 th hourly
7.TAB.OROFER XT |PO|OD
8.TAB.SHELCAL 500 mg PO OD
9.TAB.NICARDIA 10 mg PO BD. (If SBP >110mmhg )
Day 3:Salt and fluid restriction diet.
1.INJ.LASIX 40mg IV BD .
2.INJ.MONOCEF 1 g | IV | BD.
3. Tab. Pan 40 mg | PO| OD.
4.INJ. HAI S|C acc to GRBS.
5.INJ.ZOFER 4mg | IV| .
6..neb with IPRAVENT 8th hourly .
BUDECORT 12 th hourly
7.TAB.OROFER XT |PO|OD
8.TAB.SHELCAL 500 mg PO OD
9.TAB.NICARDIA 10 mg PO BD. (If SBP >110mmhg )
DAY 4 Salt and fluid restriction diet.
1.INJ.LASIX 40mg IV BD .
2.INJ.MONOCEF 1 g | IV | BD.
3. Tab. Pan 40 mg | PO| OD.
4.INJ. HAI S|C acc to GRBS.
5.INJ.ZOFER 4mg | IV| .
6..neb with IPRAVENT 8th hourly .
BUDECORT 12 th hourly
7.TAB.OROFER XT |PO|OD
8.TAB.SHELCAL 500 mg PO OD
9.TAB.NICARDIA 10 mg PO BD. (If SBP >110mmhg )
DAY 5 :Salt and fluid restriction diet.
1.INJ.LASIX 40mg IV BD . (If SBP >110mmhg )
2.INJ.MONOCEF 1 g | IV | BD.
3. Tab. Pan 40 mg | PO| OD
4.INJ.ZOFER 4mg | IV| TID.
5.TAB.OROFER XT |PO|OD
8.TAB.SHELCAL 500 mg PO OD
9.TAB.NICARDIA 10 mg PO TID. . (If SBP >110mmhg )
10.neb with MUCOMIST 8 th hourly
DUOLIN 8 th hourly
Budecort 12 th hourly
11.O2 inhalation @4-6
12.ORAL SUCTIONING AND PHYSIOTHERAPY.
Day 6:Salt and fluid restriction diet.
1.INJ.LASIX 40mg IV BD . (If SBP >110mmhg )
2.INJ.MONOCEF 1 g | IV | BD.
3. Tab. Pan 40 mg | PO| OD
4.INJ.ZOFER 4mg | IV| TID.
5.TAB.OROFER XT |PO|OD
8.TAB.SHELCAL 500 mg PO OD
9.TAB.NICARDIA 10 mg PO TID. . (If SBP >110mmhg )
10.neb with MUCOMIST 8 th hourly
DUOLIN 8 th hourly
Budecort 12 th hourly
11.O2 inhalation @4-6
12.ORAL SUCTIONING AND PHYSIOTHERAPY.
