70 yr old male patient with shortness of breath ,pedal oedema

70 year old male patient presented to the casuality with the 

CHIEF COMPLAINTS:- 

S.O.B since 15 days 

loss of appetite since 15 days

decreased urine output since 10 days

pedal oedma since 10 days 

HISTORY OF PRESENTING ILLNESS:-

He was apparently asymptomatic 14 years back then he suddenly developed slurred speech and was observed having an abnormal gait.

 then he was taken to a neuro surgeon where he was managed conservatively for a week and was on medication for 4 years . ( medication unknown, indication unknown).

Then after 4 years he was having severe SOB and was taken to a hospital where he was diagnosed with COPD and the medication dose was decreased and his symptoms subsided.

In 2018 , then he had a traumatic injury to the leg which was not healing and was taken to thehospital where rountine check up was done to find to have Type 2 DM .

Then in 2021 he developed bilateral pedal edema and on investigations it was found that CREATININE was high and diagnosed as CKD

and Now he presented with the  SOB since 10-15 days. Grade 4 since 3 days.i.e.,( SOB on rest 

not associated with palpitations, sweating

loss of appetite since 15 day

decreased urinary output since 10 days

No history of hematuria, burning micturition. 

Bilateral pitting type of  pedal edema since 10 days

he was taken to a local hospital where they found to have higher creatinine and was sent here for further management.

PAST HISTORY:- 

HTN since 14 years and on medication since then

( drug dose unknown)

DM since 4 years and on medication ( drug and dose unknown

known case of CKD since 2 years

no history of TB ,Asthma ,CAD,leprosy.


PERSONAL HISTORY:-

Diet - mixed

appetite - decreased

bowel and bladder - Regular

sleep - adequate

Addictions - smoked for 15 years and stopped smoking after diagnosed with COPD in 2012 .

occasionally alcohol

No surgeries done in the past.

FAMILY HISTORY:- 

No relevant family history

ALLERGIC HISTORY:- 

no allergies for any kind of drugs and food.

GENERAL EXAMINATION:- 

patient was semi - conscious and is on ventilator 

not well nourished and weakly built.

 Pallor present.

No icterus 

No cyanosis 

No clubbing

No lymphadenopathy

pitting type of edema (bilateral)

VITALS:- 

Temperature:- febrile

P.R :- 100

R.R :- 24

BP :- not measured

GRBS :- 177mg%

SYSTEMIC EXAMINATION:-

RESPIRATORY SYSTEM:-

INSPECTION:-

Antero - posterior diameter increased

on inspection and palpation:- Trachea is central

AUSCULTATION:-

Bilateral air entry present .

FINE CREPTS are heard on 4 areas

right and left infra axillary

and right and left infra scapular .


CARDIO VASCULAR SYSTEM:-

S1 ,S2 heard 

No Murmurs heard

PER ABDOMEN

shape of abdomen:- Scaphoid

no temderness

no palpable organs

bowel sounds - present


CENTRAL NERVOUS SYSTEM:-

patient is semi conscious .

Signs of meningeal irritation:- negative

cranial nerves - not done as he is on ventilation

sensory system - not done

motor system - not done

INVESTIGATIONS:-


Random blood sugar on 31/7/22 :-


LFT on 31/7/22 :-

RFT on 31/7/22 :-

Serum Iron on 31/7/22 :-

HEMOGRAM On 31/7/22:-

BLOOD GROUPING :- A Group( +ve )

SEROLOGY:- Anti HCV ab -non reactive

HIV RAPID TEST -NON REACTIVE

HBs Ag rapid -  negative


ABG on 31/7/22:-



X ray on 31/7/22 at 10:46 am



ABG on 1/8/22:- 

ECG on 1/8/22 :-



RFT on 1/8/22 :-



LFT on 1/8/22 :- 



X ray on 1/8/22 on 3:06 am 



X ray on 1/8/22 on 12:25 pm



ABG on 2/8/22:-



X ray on 2/8/22 at 7:11 am


ABG on 3/8/22 :- at 8:00 am


Blood urea on 3/8/22:-


Haemogram on 3/8/22:- 


Serum creatinine on 3/8/22:-


Serum electrolytes on 3/8/22:-


ABG at 3:00 am :-


ABG at 5:30 pm :-


ABG at 4/8/22:-6:00am


RFT on 4/8/22:-


DIAGNOSIS:-


Acute excerbation of COPD.

CKD secondary to diabetic nephropathy

 Anemia of chronic disease.

HTN since 14 years, Type 2 DM since 4 years.


PLAN OF CARE :- Supportive management 


TREATMENT:-

1) Fluid restriction less than 2L/day

2)Salt restriction 

3) NEB - DUOLIN 8 th hrly

                BUDECOID 12 hrly

4) I.V PIPTAZ 2.25 gm IV BD 

5) I.V PAN 40 mg BD 

6)LASIX 60 mg IV BD

7) HYDRO CORTI 100 mg

8) INJ NEOMOL 1g IV

9)INJ LEVOFLOX 

10)INJ ERYTHROPOIETIN 4000 IU 

11) T Shelcal 500 mg

12)NODOSIS 500 mg

13) GRBS charting 6 th hrly

14) vitls charting 4 th hrly

DEATH CERTIFICATE:-

5/8/22:-

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