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