35year old female with Shortness of breath,b/l pedal edema
35 F WITH AKI ON CKD
A 35 year female, resident of nalgonda came to casualty with
1) shortness of breath since 5 days
2)b/l pedal edema since 20 days
3) decreased urine output since 20 days,
Facial puffiness
C/o cough with expectoration, yellowish in colour,
#History of presenting illness
Pt was apparently asymptomatic 1 month back then she developed chest pain for which she visited local hospital in miryalaguda , on evaluation she was diagnosed to have chronic kidney disease and low hemoglobin, 2PRBC Transfusions were done
After PRBC transfusion she developed b/l pedal edema, which subsided on medication.,
5 days back she developed SOB a/w PND and orthopnea aggrevating on walking and relieving on sleeping
20 days back she developed b/l pedal edema,
And reduced urine output and when she passes urine there is turbid type of urine
And facial puffiness.
1 PRBC transfusion done in Nalgonda hospital yesterday.
#Past history
K/c/o HTN since 3 year's
Not a k/c/o DM, asthma, TB.
#personal history
Diet - mixed
Appetite - lost
Sleep - inadequate
Bladder and bowel movements- regular
No addictions
#Family history
Not significant
#General examination
patient is conscious , coherent , co-operative and moderately built
Pallor - present
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Pedal edema - b/l present
Vitals:on admission
Afebrile
Bp: 170/100 mm hg
PR: 99 bpm
RR: 22 cpm
SpO2: 87% @RA
#systemic examination
CVS: S1,S2 +
RS: BAE+
P/A: SOFT, NON TENDER
CNS: NAD
Outside reports on 30/11/21:
On 02/12/21:
On 17/12/21:
#Provisional diagnosis
AKI ON CKD (stage v), with egfr: 5ml/hr, with metabolic acidosis ( resolving ), with b/l pleural effusion with k/c/o HTN since 10 years.
#Treatment
1. Head end elevation upto 30'
2. O2 supplementation if SpO2 < 90%
3. Inj. Lasix 40mg iv tid
4. Inj. PIPTAZ 2.25gms IV BD ( D1)
5. TAB. NICARDIA 10MG PO BD
6. TAB. NODOSIS 550MG PO BD
7. TAB. SHELCAL 500 MG PO OD
8. NEB. WITH SALBUTAMOL 2 RESIPULES / 4TH HRLY,
9. INJ. ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE
10. SYP. ASCORYL PO TID
11. HRLY VITALS MONITORING.
Day 2:
Pt shifted to CKD ward
35 year old female
S:
Sob reduced
Pedal edema reduced
O:
Pt is c/c/c
Pallor +
B/l Pedal edema +
No icterus, cyanosis, clubbing, lymphadenopathy
Afebrile
Bp: 160/80 mm hg
PR: 88 bpm
RR: 22 cpm
SpO2: 92% @RA
CVS: S1,S2 +
RS: BAE+, decreased breathsounds in b/l ISA, MSA
P/A: SOFT, NON TENDER
CNS: NAD
A: AKI ON CKD (stage v), with egfr: 5ml/hr, with metabolic acidosis ( resolving ), with b/l pleural effusion with k/c/o HTN since 10 years.
P:
1. Head end elevation upto 30'
2. O2 supplementation if SpO2 < 90%
3. Inj. Lasix 40mg iv tid
4. Inj. PIPTAZ 2.25gms IV BD ( D2)
5. TAB. NICARDIA 10MG PO BD
6. TAB. NODOSIS 550MG PO BD
7. Tab. Orofer XT PO/OD
8. TAB. SHELCAL 500 MG PO OD
9. NEB. WITH SALBUTAMOL 2 RESIPULES / 4TH HRLY,
10. INJ. ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE
11. Inj. Iron sucrose 1 amp in 100ml NS
12. SYP. ASCORYL PO TID
13. HRLY VITALS MONITORING
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