55 yr old female
A 55 year old female came to casualty with complaints of SOB on exertion since 10 days.
She was apparently asymptomatic 10 days ago.
-she is experiencing SOB on exertion since 10 days which has been progressive (didn’t relieve with diuretics)
- pedal edema and facial puffiness since 7 days ( resolved now)
- H/o loss of appetite since 10 days
- H/o abdominal distension
- No H/o decreased urine output
-H/o low back pain since 3 years
- h/o NSAID use since 10 days
Diagnosed with diabetes since 15 years and on Inj HAI 4U TID
Hypertension since 20 years, on amlodipine 10mg.
- H/o gynecological surgery..underwent hysterectomy ?
O/E
she is conscious, coherent and cooperative
Pallor - present
Vitals -
Temp - afebrile
PR- 100bpm
RR - 22cpm
BP - 140/70 mmhg
Spo2 - 98% at room air
CVS - s1,s2 +
RS - BAE +
P/A - soft, non tender. Bowel sounds +
CNS -NAD
CVS-S1,S2 Heard
Resp-NVBS
Clinical images
Provisional diagnosis:
Diabetic nephropathy
With type 2 DM and HTN
With heart failure with preserved ejection fraction.
Cardiorenal syndrome - type V
INVESTIGATIONS:
Treatment
Day 1
1.Inj. Lasix 40 mg/IV/TID(ONLY IF SBP>110MMHG)
2. INJ.Pan 40mg Iv/OD
3. TAB. AMLONG 10 MG/PO/OD
4. INJ. HAI S/C
5.TAB. NODODSIS 500MG PO/BD
6. TAB. SHELCAL CT PO/0D
7. TAB. OROFER XT PO/BD
Day 2
1.Inj. Lasix 40 mg/IV/TID(ONLY IF SBP>110MMHG)
2. INJ.Pan 40mg Iv/OD
3. TAB. AMLONG 10 MG/PO/OD
4. INJ. HAI S/C
5.TAB. NODODSIS 500MG PO/BD
6. TAB. SHELCAL CT PO/0D
7. TAB. OROFER XT PO/BD
Day 3
1.Inj. Lasix 40 mg/IV/TID(ONLY IF SBP>110MMHG)
2. INJ.Pan 40mg Iv/OD
3. TAB. AMLONG 10 MG/PO/OD
4. INJ. HAI S/C
5.TAB. NODODSIS 500MG PO/BD
6. TAB. SHELCAL CT PO/0D
7. TAB. OROFER XT PO/BD
Day 4
1.Inj. Lasix 40 mg/IV/TID(ONLY IF SBP>110MMHG)
2. INJ.Pan 40mg Iv/OD
3. TAB. AMLONG 10 MG/PO/OD
4. INJ. HAI S/C
5.TAB. NODODSIS 500MG PO/BD
6. TAB. SHELCAL CT PO/0D
7. TAB. OROFER XT PO/BD
Day 5
SOAP NOTES
S:
-- SOB Decreased
No fresh complaints
O:
-- bp- 180/100 mmHg
Pr- 65 BPM
Rr- 20cpm
Cvs- S1+ S2+
Resp- BAE+
Per abdomen- soft , non tender
Cns- nfnd
A:
Provisional diagnosis:- Heart failure with preserved ejection fraction:- Ef --. 58% with Renal failure secondary to RPGN
With k/c/o DM
With k/c/o HTN
With s/p post hysterectomy status with cardiorenal type 5 with anaemia of chronic disease.
P:-
1.Inj. Lasix 40 mg/IV/TID(ONLY IF SBP>110MMHG)
2. INJ.Pan 40mg Iv/OD
3. TAB. AMLONG 10 MG/PO/OD
4. INJ. HAI S/C
5.TAB. NODODSIS 500MG PO/BD
6. TAB. SHELCAL CT PO/0D
7. TAB. OROFER XT PO/BD
Day 6
1.Inj. Lasix 40 mg/IV/TID(ONLY IF SBP>110MMHG)
2. INJ.Pan 40mg Iv/OD
3. TAB. CINOD 10 MG/PO/BD
4. INJ. HAI S/C
5.TAB. NODODSIS 500MG PO/BD
6. TAB. SHELCAL CT PO/0D
7. TAB. OROFER XT PO/BD
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