A 45 year old male with SOB and edema


45 male with SOB @rest
HOPI-
Grampanchayat worker came to casualty with c/o SOB at rest since 4 days, anasarca since 4 months
Pt was apparently asymptomatic 3 years back and had h/o chronic alcohol intake- had sudden onset involuntary movements of b/l UL, LL lasted for 15 min and frothing from mouth with uprolling of eyes 
(+) with no post ictal confusion/involuntary micturition/defecation
Taken to a hospital where MRI was done and pt advised to stop taking Alcohol, started on T.Eptoin 100mg po/bd since then.
Then he had episodes of 5-6 since 2 years
4 months back, while he was lying on the bed, he had a seizure and fall from bed leading to fracture of right hip  
Then pt was taken to hospital and said to have low Hb and renal failure
.3 units PRBC tranfusion was done 4 months back and then pt developed pedal edema which was insidious in onset, gradually progressive to anasarca in 4 months
SOB- sudden onset, rapidly progressive with class 4(NYHA classification) with orthopnea and PND

N/c/k/o DM, HTN, BA, CAD, CVA
H/o TB 24 years back, ATT- 6 months
Alcohol addiction since 30 years, last alcohol intake 4 months back

No significant family history

O/E 
TEMP- afebrile
BP- 130/90 mmhg
Pr- 81 BPM
RR- 26CPM
SPO2- 100% at RA
GRBS- 166MG/DL

No icterus, cyanosis, clubbing, lymphedema
Moderate pallor present(+)
B/L pitting type of edema of feet (+) anasarca (+)


CVS- S1 S2 heard, JVP-N
RS- dyspnoe present, b/l crepts (+) in IAA, IMA, ISA
P/A- distended, free fluid (+), bowel sounds heard
CNS- NFND




PROVIONAL DIAGNOSIS-
AKI on CKD with Anemia 2° to CKD with Pulmonary Edema with Metabolic acidosis with seizure disorder with old Right Hip fracture

Dialysis one session done on 30/12/21
1 unit PRBC tranfusion done

Rx:
Fluid restriction <1.5 l/day
Salt restriction <2gm/day
Inj. Ceftriaxone 1gm iv bd
Inj. Lasix 80mg iv/stat--> 40mg iv/bd (8am--4pm--x)
Inj. PANTOP 40mg iv od
Inj.. ZOFER 4mg iv SOS
T. Nodosis 550mg po/bd
Cap Bio-D3 0.25 mcg po/od
T. Orofer-XT po/bd
T. Eptoin 100mg po/bd
Inj. Erythropoietin 4000iu s/c weekly once
Strict I/o charting
Vitals monitoring 4th hrly



1/1/22 
Soap Notes

S - sob reduced compared to yesterday
No fever spikes

O- Pt drowsy, but arousable 
Temp- 99f
Bp- 140/90mmhg
PR- 92bpm
RR- 22cpm
Spo2- 94% at ra

Rs-bae+
Cvs-s1s2+
P/a- soft, bs+
Cns- gcs E3V4M5

2 sessions of hemodialysis done 30/12(Ug 1.5lit), 31/12(Uf 2lit)

A- chronic renal disease with metabolic acidosis
Anemia sec to ? Chronic kidney disease
H/o seizure disorder
Old rt hip fracture

P-Fluid restriction <1.5lt / day
Inj lasix 40mg iv bd
Tab orofex xt po od
Inj erythropoietin 4000sc weekly once
I/o charting
Bp/PR /spo2 charting 4th hrly


S - sob reduced compared to yesterday
No fever spikes

O- Pt drowsy, but arousable 
Temp- 99f
Bp- 140/90mmhg
PR- 92bpm
RR- 22cpm
Spo2- 94% at ra

Rs-bae+
Cvs-s1s2+
P/a- soft, bs+
Cns- gcs E3V4M5

2 sessions of hemodialysis done 30/12(Ug 1.5lit), 31/12(Uf 2lit)

A- chronic renal disease with metabolic acidosis
Anemia sec to ? Chronic kidney disease
H/o seizure disorder
Old rt hip fracture

P-Fluid restriction <1.5lt / day
Inj lasix 40mg iv bd
Tab orofex xt po od
Inj erythropoietin 4000sc weekly once
I/o charting
Bp/PR /spo2 charting 4th hrly



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