CKD,acute exacerbation of COPD,diastolic heart failure(HFPEF)

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:
65 year old male who was a daily labourer and stopped working 2 years back,came with chief complaints of bilateral pedal edema since 10days ,facial edema since 10 days,shortness of breath since 7 days and cough on and off since 7 days, decreased urine output since 7 days.
Patient was apparently asymptomatic 2 years back,then he developed bilateral pedal edema, facial edema,productive cough,low back ache,shortness of breath and visited local hospital and there he was diagnosed with renal problem(reports not available) and used medications for that.on others advise he visited an higher centre and there he was diagnosed as CKD (reports not available)and was on medical mangement.
Now presented with the complaints of bilateral pedal edema since 10days, pitting+, gradually progressive in nature, no aggravating and relieving factors,facial edema since 10 days,Shortness of breath grade 3,gradually progressive, no aggravating and relieving factors,decreased urine output since 10days,decreased frequency, cough on and off since 7 days ,productive cough.

K/c/o HTN since 5 years and on regular medication on tab. Amlovas 5mg po od.

Not a k/c/o DM,CAD, CVA, TB.

 History of alcohol intake occasionally since 40years and stopped taking it since 6months and gives history of  smoking (18 beedis per day)for 25 years and stopped smoking since 6 months


 O/E

Patient is conscious coherent cooperative 

Pallor present

No Icterus, cyanosis, clubbing,Lymphadenopathy 

Pedal edema + which is pitting type

Vitals:

Temp:98.5 F

RR 26cycles/min

BP:130/70mmHg

PR:96/min

SpO2:97% on RA

Systemic examination:

CVS:

s1 s2 +

 no murmurs

RS:

Bilateral air entry present

CNS:

all higher mental functions are normal

Cranial nerves intact

Sensory system normal

Motor system normal

Cerebellar signs normal

No meningeal signs

P/A:

soft

Non tender

no organomegaly

bowel sounds heard

Investigations:

Hemogram-

Hb -5.2
Tlc-13,100
Pcv-16.8
MCH-32.6
MCHC-34.6
Plt-2.5 

LFT-

TB-1.12

DB-0.20

Sgot-18

Sgpt-15

Alp-167

TP-6.4

Albumin-3.7

A/g-1.42


RFT-.


 

Serology-

Hiv-non rective
HbsAg -negative
Hcv-negative


Ecg-





CXR-




Outside ct report:


Usg-




Treatment-

1.salt and water restriction

2.tab.nodosis 500mg bd po

3.tab.shelcal od po

4.tab.pantop 40 mg od po

5.tab.clinidipine 10 mg bd po

6.tab.lasix 40 mg bd po

7.neb. with salbutamol 4 respules over 20 min stat.

8.ivf-25%dextrose with HAI 8 u/iv stat over half an hour

Dialysis was done

Day 2 -

No fresh complaints

O/E pt c/c

I/O -600/400

Grbs:126mg/dl at 8am

PR 96/min

BP 130/80mmhg

Cvs s1s2 +

Rs:BAE +

P/A soft, NT

CNS:no FND

RFT-

Urea-205

Creat-11.1

Uric acid-3.2

Ca-10.1

Phosphorus-5.8

Na-139

K-5.2

Cl-106

Abg-

PH-7.34

Pco2-21.0

Po2-113

Hco3-11.1

St.Hco3-13.8

BEB- -13.4

BEecf- -13.7

O2 sat-96.6

Treatment- 

1.salt and water restriction

2.tab.nodosis 500mg bd po

3.tab.shelcal od po

4.tab.pantop 40 mg od po

5.tab.clinidipine 10 mg bd po

6.tab.lasix 40 mg bd po

7.neb. with salbutamol 4 respules  8th hrly

Dialysis was done.

Day 3

No fresh complaints

O/E pt c/c

I/O -720/400

Grbs:123mg/dl at 8am

PR 79/min

BP 140/80mmhg

Cvs s1s2 +

Rs:BAE +

P/A soft, NT

CNS:no FND

RFT-

Urea-73

Creat-5.8

Uric acid-2.1

Ca-10.9

Phosphorus-6.0

Na-140

K-3.9

Cl-100


Hb-



Abg-

PH-7.47

Pco2-39.2

Po2-81

Hco3-28.5

St.Hco3-28.9

BEB- 4.9

BEecf- 4.9

O2 sat-94.8

CUE-



Treatment-

1.salt and water restriction

2.tab.nodosis 500mg bd po

3.tab.shelcal od po

4.tab.pantop 40 mg od po

5.tab.clinidipine 10 mg bd po

6.tab.lasix 40 mg bd po

7.neb. with salbutamol with 4 respules 8 th hrly

8.tab.orofer od po

9.tab.augmentin 625mg od po

10.syrup ascoril 5ml tid

11.kayexalate sachets,1 sachet in 1 cup of water,4 sachets per day

Day 4 

C/o productive cough

O/E pt c/c

I/O -400/300

Grbs:116mg/dl at 8am

PR 94/min

BP 150/80mmhg

Spo2-93% at ra

Cvs s1s2 +

Rs:BAE +

P/A soft, NT

CNS:no FND

Treatment-

1.salt and water restriction

2.tab.nodosis 500mg bd po

3.tab.shelcal od po

4.tab.pantop 40 mg od po

5.tab.clinidipine 10 mg bd po

6.tab.lasix 40 mg bd po

7.neb. with salbutamol with 4 respules 8 th hrly

8.tab.orofer od po

9.tab.augmentin 625mg od po

10.syrup ascoril 5ml tid

11.kayexalate sachets,1 sachet in 1 cup of water,4 sachets per day

Serum k+ :4.0


Day 5 

o/E pt c/c

I/O -600/300

Grbs:109mg/dl at 8am

PR 97/min

BP 140/80mmhg

Spo2-92% at ra

Cvs s1s2 +

Rs:BAE +

P/A soft, NT

CNS:no FND

Treatment-

1.salt and water restriction

2.tab.nodosis 500mg bd po

3.tab.shelcal od po

4.tab.pantop 40 mg od po

5.tab.clinidipine 10 mg bd po

6.tab.lasix 40 mg bd po

7.neb. with salbutamol with 4 respules 8 th hrly

8.tab.orofer od po

9.tab.augmentin 625mg od po

10.syrup ascoril 5ml tid

11.kayexalate sachets,1 sachet in 1 cup of water,4 sachets per day

Blood urea-72

Serum elect-

Na-147

K-4.0

Cl-106

Serum creat-4.0 

Cxr-

2decho-



Abg-

PH-7.37

Pco2-20.2

Po2-79

Hco3-25.5

St.Hco3-25.1

BEB- 0.8

BEecf- 0.9

O2 sat-90.8


Day -6

O/E pt c/c

I/O -500/nil

Grbs:107mg/dl at 8am

PR 99/min

BP 140/90mmhg

Spo2-89% at ra

Cvs s1s2 +

Rs:BAE +

P/A soft, NT

CNS:no FND

Treatment-

1.salt and water restriction

2.tab.nodosis 500mg bd po

3.tab.shelcal od po

4.tab.pantop 40 mg od po

5.tab.clinidipine 10 mg bd po

6.tab.lasix 40 mg bd po

7.neb. with salbutamol with 4 respules 8 th hrly

8.tab.orofer od po

9.tab.augmentin 625mg od po

10.syrup ascoril 5ml tid

11.kayexalate sachets,1 sachet in 1 cup of water,4 sachets per day

Dialysis was done


Hemogram:



CXR-




In view of falling satrurations,poor GCS pt.  was intubated.

Vitals after intubation:

HR-96bpm

Bp-100/60

Spo2-100% with fio2 40%

Mode-IPPV


Tv-420ml

PEEP-5cm H2o

Day 7-

Pt.c/c/c

GCS-E4V1M6

Bp-160/100

Pr-120bpm

RS-BAE+

Spo2-94 with o2

I/0-700/200ml

Treatment :

1.fluid  and salt restriction

2.inj.piptaz 2.25gm iv bd

3.tab.clinidipine 10 mg  sos

4.tab nicardia 10mg sos

5.neb. with duolin 2nd hrly

                 Budecort 8th hrly

6.ET and oral suctioning

7.Rt feeds 200ml milk 2nd hrly

8.inj.lasix 40mg iv tid

9.tab.clonidine 0.1mg bd

Day-8

Pt.c/c/c

GCS-E4V1M6

Bp-180/100

Pr-120bpm

RS-BAE+

I/0-650/nil

Spo2-95 with o2

CPAP-VC

Fio2-30%-21%

PEEP-5cm

Treatment :

1.fluid  and salt restriction

2.inj.piptaz 2.25gm iv bd

3.tab.clinidipine 10 mg  sos

4.tab nicardia 10mg sos

5.neb. with duolin 2nd hrly

                 Budecort 8th hrly

6.ET and oral suctioning

7.Rt feeds 200ml milk 2nd hrly

8.inj.lasix 40mg iv tid

9.inj.pan 40mg iv od

10.tab.clonidine 0.1mg bd

Investigations-

Hb:6.4

Tlc:11,500

RFT:

Urea - 91

Creat-6.4

Na-133

K-3.9

Cl-103

ABG:

PH-7.38

Pco2-37.3

Po2-48.7

Hco3-22.0

St.Hco3-22.2

Day 9

Pt.  was given a spontaneous breath trials with room air on T piece for about 60 min.of time.

O/e:

Pt. Conscious

Bp-140/80

Pr-102

Cvs- s1,s2 heard

Rs-BAE+,coarse crepts in rt. iaa and lt. Iaa

I/o-700/nill

Abg:

Ph-7.42

Pco2-30.9

Po2-96.6

So2-95%

Hco3-24.5

Later, extubation was done

Post extubation vitals

Pt. C/c

Bp-140/70

Pr-82

Spo2-93%

Cvs-s1,s2 heard

Rs-blae+ coarse crepts in rt.,lt. IAA

Abg after extubation

Ph-7.42

Pco2-38.1

Po2-105

So2-96%

Hco3-23.8

Day 10:

Pt. C/c

Bp-140/90

Pr-87

Spo2-94%

Cvs-s1,s2 heard

Rs-blae+ coarse crepts in rt.,lt. IAA

I/o-1300/200

Treatment :

1.fluid  and salt restriction

2.inj.piptaz 2.25gm iv bd

3.tab nicardia 10mg sos

4.neb. with duolin 2nd hrly

                 Budecort 8th hrly

5.inj.lasix 40mg iv tid

6.inj.pan 40mg iv od

7.tab.arkamine 0.1 mg po tid

Dialysis was done

Hemogram

Hb-6.4

Tlc-9400

Plt-2.69

Pcv-19.2

MCV-88.9

MCH-29.7

MCHC-33.3

Abg:

Ph-7.44

Pco2-38.4

Po2-98.9

So2-96%

Hco3-25.8

RFT:

Urea-134

Creat-8.4

Na-136

K-3.3

Cl-101

Ecg-


Cxr-







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