A 65 year Old female,home maker with complaints of Pedal Edema on & off since 2 months
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A 65 year Old female,home maker was brought to casualty with chief complaints of
Pedal Edema on & off since 2 months which was continuous since 1month
Abdominal distension since 1 week
SOB since 3 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year back then she had covid which was recovered and 5 months later on routine checkup she was found to be having a s.creatinine of 4.5 and high blood pressure for which she was kept on conservative management.
She was asymptomatic for 5 months after which she developed Pedal edema, pitting type, aggregated during day time and relieved during nights, She went to local hospital where serum creatinine levels were around 5mg/dL for which she took medication and got relieved.
1week back she developed abdominal distension, which was gradual in onset associated with shortness of breath grade 3 since 3 days.
PAST HISTORY:
Known case of Hypertension since 4 months in regular medication
Not a known case of DM, asthma
PERSONAL HISTORY:
Diet - Mixed
Appetite- decreased
Bowel and bladder - Oliguria since one week
No addictions
FAMILY HISTORY-
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent , co operative
VITALS :
TEMPERATURE-98F
BP -130/80 mm hg
PR -70bpm
RR - 16Cpm
Pallor present
No Icterus , Cyanosis , Lymphadenopathy
Per abdomen findings :
On inspection, Abdominal distension is present, Transverse slit like umblicus is present
On percussion, Fluid thrill present
CVS :
S1,S2 heard
No murmurs
RESPIRATORY SYSTEM :
BAE present, NVBS
CNS :
NAD
INVESTIGATIONS:
ARTERIAL BLOOD GAS :
Ph -7.48
PCO2 -40.8
PO2- 55.9
Hco3- 30.1
HEMOGRAM:
Hb -5.9
TLC -4900
N/L/E/M/B - 64/22/04/10/00
PCV -18.7
MCV -71.4
PLT- 1.6 lakhs
ULTRASOUND ABDOMEN:
BILATERAL GRADE 3 RPD
BILATERAL SIMPLE RENAL CORTICAL CYST (Sub centimetric )
GROSS ASCITES
ECG :
Per abdomen:
Pitting type edema:
AKI ON CKD WITH GROSS ASCITES
TREATMENT GIVEN :
1)INJ LASIX 40MG IV/BD
2)INJ PANTOP 40MG IV OD
3)INJ ZODER 4MG IV OD
4)T FEBUXOSTAT 100MG PO /OD
5)T NICARDIA 10MG BD
6)T SHELCAL PO /OD
7)T BIO D3 PO ONCE WEEKLY
8)INJ ERYTHROPOIETIN 4000IV S/c ONCE WEEKLY
9)FLUIDS <1.5L and SALT <2.5G
10)MONITAR VITALS , I/O CHARTING
DOA : 9/05/22
SOAP NOTES DAY 2:
S
Pedal Edema on & off since 2 months which was continuous since 1month
Abdominal distension since 1 week
SOB since 3 days
O
Patient is conscious, coherent , co operative
VITALS :
TEMPERATURE-98F
BP -130/80 mm hg
PR -70bpm
RR - 16Cpm
No pallor, Icterus , Cyanosis , Lymphadenopathy
Per abdomen findings :
On inspection, Abdominal distension is present, Transverse slit like umblicus is present
On percussion, Fluid thrill present
CVS :
S1,S2 heard
No murmurs
RESPIRATORY SYSTEM :
BAE present, NVBS
CNS :
NAD
INVESTIGATIONS:
ARTERIAL BLOOD GAS :
Ph -7.48
PCO2 -40.8
PO2- 55.9
Hco3- 30.1
HEMOGRAM:
Hb -5.9
TLC -4900
N/L/E/M/B - 64/22/04/10/00
PCV -18.7
MCV -71.4
PLT- 1.6 lakhs
ULTRASOUND ABDOMEN:
BILATERAL GRADE 3 RPD
BILATERAL SIMPLE RENAL CORTICAL CYST (Sub centimetric )
GROSS ASCITES
RFT :
Urea 168
Creatinine 11.0
Uric acid 6.9
Sodium 145
Potassium 3.7
Chloride 99
LFT :
Total bilirubin 0.62
Direct Bilirubin 0.15
SGOT 21
SGPT 11
Alkaline phosphatase 141
Total proteins 7.1
Albumin 3.95
A/G 1.25
ABG
PH 7.48
PCO2 40.8
PO2 55.9
HCo3 30.1
HEMOGRAM
HB 5.9
TLC 4900
N/L/E/M/B 64/22/4/10/0
A
DIAGNOSIS:
AKI ON CKD WITH GROSS ASCITES
P
TREATMENT GIVEN :
1)INJ LASIX 40MG IV/BD
2)INJ PANTOP 40MG IV OD
3)INJ ZODER 4MG IV OD
4)T FEBUXOSTAT 100MG PO /OD
5)T NICARDIA 10MG BD
6)T SHELCAL PO /OD
7)T BIO D3 PO ONCE WEEKLY
8)INJ ERYTHROPOIETIN 4000IV S/c ONCE WEEKLY
9)FLUIDS <1.5L and SALT <2.5G
10)MONITAR VITALS , I/O CHARTING
ICU BED 5, SOAP NOTES DAY 3 :
S
Pedal Edema present
Abdominal distension present
No complaints of SOB
No fresh complaints
O
Patient is conscious, coherent , co operative
VITALS :
TEMPERATURE-98F
BP -140/80 mm hg
PR -80bpm
RR - 16Cpm
Pallor present
No Icterus , Cyanosis , Lymphadenopathy
Per abdomen findings :
On inspection, Abdominal distension is present, Transverse slit like umblicus is present
On percussion, Fluid thrill present
CVS :
S1,S2 heard
No murmurs
RESPIRATORY SYSTEM :
BAE present, NVBS
CNS :
NAD
INVESTIGATIONS:
HEMOGRAM:
Hb -6.8
TLC -8,400
N/L/E/M/B - 73/20/3/4/0
PCV -22.1
MCV -72.2
PLT- 1.6 lakhs
A
DIAGNOSIS:
AKI ON CKD WITH GROSS ASCITES
P
TREATMENT GIVEN :
1)INJ LASIX 40MG IV/BD
2)INJ PANTOP 40MG IV OD
3)INJ ZOFER 4MG IV OD
4)T FEBUXOSTAT 100MG PO /OD
5)T NICARDIA 10MG BD
6)T SHELCAL PO /OD
7)T BIO D3 PO ONCE WEEKLY
8)INJ ERYTHROPOIETIN 4000IV S/c ONCE WEEKLY
9)FLUIDS <1.5L and SALT <2.5G
10)MONITAR VITALS , I/O CHARTING
