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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