55 Y /M WITH HEART FAILURE , ? COPD , BELOW KEE AMPUTATION
55 Y /M WITH HEART FAILURE , ? COPD , BELOW KEE AMPUTATION
55 Y / M pt presented to casuality with c/o
Blurring of vision since 1 year
Decreased urine output since 2 months
Pedal edema since 1 month
SOB since 3 days
Distended abdomen since 2 days
Pt was apparently asymptomatic 10 yrs back , then he was diagnosed with DM type 2 , on has been using Glimi 2 mg tablets
Pedal edema was gradually progressive
SOB grade 4 was more during the night , PND
There are no aggregating and relieving factors
Pt is a k/c/o DM since 10 yrs , on Tab Glimi 2 mg
HTN since 2 yrs , on T. Telma 40 mg
Surgical history : Pt had below knee amputation 1 yr back , due to trauma to the left lower limb which developed cellulitis
Pt is an occasional alcoholic since 30 years
Chronic smoker since 20 years ( daily 1 pack of cigarette and 1 pack of beedi )
Medical h/o :
Pt is on T Atorvastatin 10 mg
T Pentoxifyllin 400 mg since 1 yr
Not a k/c/o tb , asthma
Occupation : Mason
Appetite : normal
Diet : mixed
B& B : decreased micturition
Pallor present
CVS: S1S2+
No murmurs
RS:
DYSPNEA +
Wheeze +
inspiratory crepts in b/l ISA , IAA , IMA
Trachea position-central.
Vesicular breath sounds heard
P/A:
Soft, non tender
DISTENDED
Bowel sounds heard .
CNS: NAD
Provisional diagnosis : ? AKI with right heart failure
? COPD , with left below knee amputation
K/c/o Type 2 DM since 10 yrs
HTN since 2 yrs
Clinical images :
ECG on
Investigations
On 8/12/21
S urea 169
S creat 9.8
Treatment :
Fluid restriction
Salt restriction
Inj lasix 40 mg iv bd
Inj HAI sc 8 am ....1 pm...8 pm
Neb with duolin 8 th hrly , budecort 12 hrly
16/12/21
55 Y / M
CKD ward
SOAP NOTES
DAY 9
16/12/21
S :
Blurring of vision since 1 year
Decreased urine output since 2 months
Pedal edema since 1 month
SOB since 6 days
O :
O/E
Pt is c/c/c
Temp 98.4 F
BP 140/80 mm hg
PR 81
RR 28
GRBS 96 mg/dl
CVS: S1S2+
No murmurs
RS:
BAE +
Trachea position-central.
Vesicular breath sounds heard
P/A:
Soft, non tender
DISTENDED
Bowel sounds heard .
S urea 143
S creat 8.8
P 4.6
Na 146
CNS: NAD
Provisional diagnosis : ? AKI with heart failure
? COPD , with left below knee amputation
K/c/o Type 2 DM since 10 yrs
HTN since 2 yrs
Treatment :
2 sessions of dialysis done
1) on 11/12/21
2) on 14/11/21
3 )Today 3rd session
Fluid restriction
Salt restriction
Inj lasix 40 mg iv bd
Inj HAI sc 8 am ....1 pm...8 pm
Neb with duolin 8 th hrly, budecort 12 th hrly
18/12/21
55 Y / M
CKD ward
SOAP NOTES
DAY 11
18/12/21
S :
Complaints of low back ache, generalised body pains and weakness- these causing sleep disturbance.
Thrombophlebitis of the left hand.
O :
O/E
Pt is c/c/c
Temp 98.4 F
BP 140/80 mm hg
PR 81
RR 22
GRBS 174 mg/dl
CVS: S1S2+
No murmurs
RS:
BAE +
Trachea position-central.
Vesicular breath sounds heard
P/A:
Soft, non tender
DISTENDED
Bowel sounds heard .
S urea 134
S creat 6.3
P 3.7
Na 143
CNS: NAD
Provisional diagnosis : ? AKI with heart failure
? COPD , with left below knee amputation
K/c/o Type 2 DM since 10 yrs
HTN since 2 yrs
Treatment :
2 sessions of dialysis done
1) on 11/12/21
2) on 14/11/21
3)on 16/11/21
Fluid restriction
Salt restriction
Inj lasix 40 mg iv bd
Inj HAI sc 8 am ....1 pm...8 pm
Tab.nicardia 10mg od
19/12/21
55 Y / M
CKD ward
SOAP NOTES
DAY 12
19/12/21
S :
Complaints of low back ache, generalised body pains and weakness- these causing sleep disturbance.
Thrombophlebitis of the left hand.
O :
O/E
Pt is c/c/c
Temp 98.4 F
BP 140/90 mm hg
PR 81
RR 20
GRBS 164 mg/dl
CVS: S1S2+
No murmurs
RS:
BAE +
Trachea position-central.
Vesicular breath sounds heard
P/A:
Soft, non tender
DISTENDED
Bowel sounds heard .
S urea 134
S creat 6.3
P 3.7
Na 143
CNS: NAD
Provisional diagnosis : ? AKI with heart failure
? COPD , with left below knee amputation
K/c/o Type 2 DM since 10 yrs
HTN since 2 yrs
Treatment :
2 sessions of dialysis done
1) on 11/12/21
2) on 14/11/21
3)on 16/11/21
Fluid restriction
Salt restriction
Inj lasix 40 mg iv bd
Inj HAI sc 8 am ....1 pm...8 pm
Tab.nicardia 10mg od
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