74 year old female with CKD

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CHEIF COMPLAINS

A 74-year-old female patient came to the OPD with the chief complaints of SOB and pedal edema since one day

HOPI

Patient was apparently asymptomatic two months back then she developed grade 4 SOB and pitting type of pedal edema for which she went to the hospital where she was diagnosed with kidney problem and was asked to start dialysis 


She was admitted to us on 17/7/2022 and she Received five sessions of dialysis

Last session on 27/7/22

PAST HISTORY 

Known case of DM since one year and CAD since 6 months

VITALS

temperature: afebrile

pulse rate:102bpm

RR:25/ min

BP:160/90

Spo2:83%

GRBS:117mg%


SYSTEMIC EXAMINATION 






CVS:S1S2 heard 

Jvp not raised

No murmurs heard

RESPIRATORY:grade 4 dyspnea 

B/L inspiration crepets

ABDOMEN: Normal


PROVISIONAL DIAGNOSIS 

CKD on MHD

DM

FLUID OVERLOAD  secondary to heart failure / Renal failure ..HFmEF ( EF -45%)


INVESTIGATIONS 














TREATMENT 

14/8/22

-fluid and salt restriction

-INJ lasix 80 mg IV/STAT—40 mgIV/BD(if BP>110 mm of hg)

-TAB NODOSIS 500 mg PO/BD

-TAB SHELCAL 500 mg PO/BD

-TAB OROFER XT PO/OD

-CAP. BIO D3 PO/BD (weekly once)

-GRBS 6 hrly 

- BP Monitoring four hourly

-TAB MET-XL 1.25 mg PO/BD

-TAB ECOSPRIN 

15/8/22

INJ lasix 80 mg IV/STAT

-TAB NODOSIS 500 mg PO/BD

-TAB SHELCAL 500 mg PO/BD

-TAB OROFER XT PO/OD

-CAP. BIO D3 PO/BD (weekly once)

-TAB MET-XL 1.25 mg PO/BD

-TAB ECOSPRIN 

-DOLO 650 mg PO/BD




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