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A 70-year-old woman who is a daily wage labourer by occupation presented to casuality with the complains of :
Shortness of breath since one week
Both lower limbs swelling since one week
Nausea and vomiting since three days
Decreased urine output since three days
Patient was apparently a symptomatic 5 to 6 years back then he developed low-grade fever on and off associated with generalised weakness then she went to local healthcare and diagnosed with diabetes since then she was on regular oral hypoglycaemic agents till now the interval was uneventful
one month back she had 3 to 4 episodes of loose stools which is small quantity & watery consistency for 1 to 2 days which is relieved with medication
since one week patient develops progress worsening of shortness of breath initially on exertion and now even at rest and is associated with bilateral pedal Edema initially till ankle progress now to Anasarca and decreased urine output. Cough and low grade fever on and off since 10 days.
No Burning micturation, no pain abdomen,
Known case of diabetes since 5 to 6 years
Personal history :
Appetite : decreased
Diet : mixed
Sleep : inadequate
Bladder : decreased urine output
Bowel movements: regular
Addictions :absent
General examination:
Pallor: present
Icterus: absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : present B/L pitting type of pedal edema.
Vitals:
Temperature: afebrile
Pulse: 110bpm
Blood pressure:180/80 mm of hg
Respiratory rate : 28 bpm
SpO2 : 88 on RA
GRBS : 141MG/DL
Systemic examination:
Cardiovascular system
JVP -raised
Visible pulsations: absent
Apical impulse : left 5th intercostal space in midclavicular line.
Thrills -absent
S1, S2 - heart sounds heard
Pericardial rub - absent
Respiratory system:
Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal
Shape of chest - normal
Chest movements : bilaterally symmetrically reduced
Trachea is central in position.
Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS,
Chest movements bilaterally symmetrical
AUSCULTATION
B/L diffuse crepts present.
Abdomen examination:
INSPECTION
Shape : distended
Umbilicus:normal
Movements :normal
Visible pulsations :absent
Skin or surface of the abdomen : normal
PERCUSSION- tympanic
AUSCULTATION :bowel sounds heard
Labs :
Diagnosis:
AKI on CKD 2to ?pneumonia
?Diabetic nephropathy with DM
Treatment :
1. Hemodialysis initiated on 13/6/22
2. Inj. Augmentin 625mg BD
3. Inj. Lasix 4o mg OD
4. Inj. HAL S/C TID acc to GRBS
5. T NODOSIS 500mg BD
6. T. Orofer-XT OD
7. T. Shelcal 500mg PO OD
8. T. Nicardia 20mg OD
9. Ascoryl LS 10ml TID.
1 unit blood transfusion done on 13/6/22. B positive.
4 sessions of dialysis done on 13th, 14th, 16th, 17th june.
On 13/6
Patient is discharged on 18/6/22.
Patient came for 1st MHD admission on 22/6/22.
Patient c/o pain at AV fistula operation site. Nausea and B/L lower limb swelling. no fever, no vomitings
Vitals : stable
Escalated lasix dose to 60 - X - 40mg.
Labs at this admission:
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