2/11/2020
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A 44 year old male presented to the opd with chief complaints of shortness of breath.
C/O Pedal edema since 1 week
C/o decreased Urine patient since 1 week
C/o Facial Puffiness since 1 week
C/o loss of appetite,
and 2 episodes of vomitings
Patient was apparently asymptomatic 5 days ago then he developed high grade fever associated with chills and rigors was diagnosed with typhoid and he took medication for that.
No h/o loose stools
No h/o cough
No h/o burning micturition
No h/o hematuria,melena, bleeding gums, hematemesis and no other bleeding manifestations
Known Case Of
CKD since 10 years with regular medication.
DM since 4-5 years
HTN since 1 year
He has normal appetite,takes mixed diet, regular bowel and bladder movements,no addictions.
On examination patient is conscious, coherent and cooperative
Obesed.
Pallor seen
Clubbing is seen
Vitals:
Temp-98.4 degrees F
PR-89 bpm
RR-20 cpm
BP-130/80 mm Hg
Spo2:98% at room air
RS: Bilateral air entry+;clear
P/A:soft,non tender
CVS:S1S2+
CNS: HMF Intact.
APEX BEAT- 6TH ICS LATERAL AND OUTWARD
JVP-RAISED , EPIGASTRIC PULSATIONS PRESENT
WT-83 KG
Provisional Diagnosis:
Heart failure with Preserves Ejection Fraction with EF - 45% with CKD since 10 years with DM since 5 years with HTN since 1 year.
INVESTIGATIONS:
Haemogram:
CBP :
LFT :
Ultrasound Report :
Color Doppler 20 Echo:
Radiometer ABL800 Basic :
Arterial sample type
Serum Creatinine: 3.4 mg/dl
Blood Urea : 102 mg/dl
Serum Electrolytes:
Na : 122 mEq/L
K : 4.7 mEq/L
Cl-94 mEq/L
Peripheral Smear :
RBC : Normocytic,Normochromic
WBC : Leucocytosis
Platelet : Thrombocytosis.
Treatment:
SALT RESTRICTION < 2.4 GM/DAY
FLUID RESTRICTION< 1 LT/DAY
INJ LASIX 40MG /IV/BD ( IF BP>110MHG)
INJ PANTOP 40 MG /IV/OD
TAB. NODOSIS 550 MG /PO/OD
TAB. SHELCAL 500MG /PO/OD
TAB PCM 500MG /PO/SOS
INJ. PIPTAZ 2.25 G/IV/BD(DAY 1)
INJ. NEOMOL 100 ML /IV/SOS
MONITOR VITALS HOURLY
STRICT I/O CHARTING
INJ HAI PRE MEAL S/C 8AM-2PM-8PM
GRBS MONITORING
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