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A 55 year old female , agricultural labourer by occupation ,resident of nalgonda, came to the opd with chief complaints of
1)facial puffiness since 15 days
2)pedal edema since 15 days
3) shortness of breath since 15 days
HOPI
The patient was apparently asymptomatic 7 years back then she was diagnosed with hypertension.and on irregular medication
5 years back she had trauma to her left hand (fracture)for which she took treatment in govt hospital, In her routine investigations her cretinine levels were found to be high and they were referred to Kims.She was prescribed medications for the same.
3 years back, she went to local rmp for her knee joint pains, for which she was prescribed pain medication which she used them for one year.
15 days back she gradually developed facial puffiness, bilateral pedal edema (pitting type)up to knee joint and shortness of breath ,grade 3.
She also complains of deceased urine output during the day,nocturia, constipation.
Past history:
K/C/O HTN since 7 years
On irregular medication
Personal history:
Diet -mixed
Appetite-decreased
Sleep-adequate
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent, cooperative, moderately built and nourished.
No pallor,icterus ,cyanosis,clubbing, lymphadenopathy
Bilateral pedal edema (pitting type)+
VITALS:
Bp-180/90mmhg
Pr-92bpm
Rr-20cpm
Spo2 -98% at RA
Grbs-101mg/dl
Systemic examination:
Cvs-S1,S2 +
Rs-Bae+,nvbs+
P/A- soft ,nontender
Cns- nad
Diagnosis :
Chronic kidney disease ? Secondary to frature heart failure(Renocardiac syndrome)
Treatment:
One round hemodialysis was done on 20/01/2022
1) neb with duolin 4 respules/ stat
2) INJ. LASIX 40 MG IV /BD
3) TAB. NODOSIS 550 MG PO/BD
4) TAB.SHELCAL PO/OD
5) TAB.OROFER XT PO/BD
6)INJ.ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE
7)TAB. NICARDIA 20 mg PO /BD
8)INJ HAI 12U IN 25% DEXTROSE/IV/OVER 30MINS
Day2: soap notes
S:sob resolved after hemodialysis
Pedal edema slightly reduced
Constipation -
O: bp :150/90 mmhg
Pr: 85 bpm
Rr: 20 cpm
Spo2:
A: Chronic kidney disease ? Secondary to frature heart failure(Renocardiac syndrome)
P:
INJ. LASIX 40 MG IV /BD
TAB. NODOSIS 550 MG PO/BD
TAB.SHELCAL PO/OD
TAB.OROFER XT PO/BD
INJ.ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE
TAB. NICARDIA 20 mg PO /BD
INJ HAI 12U IN 25% DEXTROSE/IV/OVER 30MINS
DAY 3 soap notes
S: complaints of sob from early morning
Dry cough since yesterday night
O:
bp :170/100
Pr: 94 bpm
Rr: 24 cpm
Spo2: 96% at RA
A: Chronic kidney disease with hyperkalemia
P: neb duolin stat given
planning for dialysis as she is complaining of sob
1) neb with duolin 4 respules/ stat
2) INJ. LASIX 40 MG IV /BD
3) TAB. NODOSIS 550 MG PO/BD
4) TAB.SHELCAL PO/OD
5) TAB.OROFER XT PO/BD
6)INJ.ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE
7)TAB. NICARDIA 20 mg PO /BD
8)INJ HAI 12U IN 25% DEXTROSE/IV/OVER 30MINS
9) SYP . Ascoryl D 10 ml po / TID
Soap notes day 4:
S:Sob resolved after hemodialysis
Facial puffiness-
Pedal edema reduced
Cough resolved
O:
bp:160/90 mmhg
Pr: 84bpm
Rr: 20cpm
Sp02: 98%at RA
A: Chronic kidney disease ? Secondary to frature heart failure(Renocardiac syndrome)
INJ. LASIX 40 MG IV /BD
TAB. NODOSIS 550 MG PO/BD
TAB.OROFER XT PO/BD
INJ.ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE
TAB. NICARDIA 20 mg PO /BD
INJ HAI 12U IN 25% DEXTROSE/IV/OVER 30MINS
Tab. ATENAM sos OD
