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I am Nomika Alli (Roll no 179) of 9th Sem MBBS.
A 67 year old Male R/O Devarakonda , came to the casualty on 2nd December 2023 with complaints of Shortness of breath since 10 days and pedal & facial edema since 8 days
HISTORY OF PRESENT ILLNESS:
Patient came in drowsy but arousable state to the casualty . He was apparently asymptomatic 10 days back , then he developed Shortness of breath which is insidious in onset, gradually progressive in nature, aggravating on exertion and relieved on taking rest, progressed from grade II to grade III- IV (Modified MRC)
Orthopnea, Paroxysmal nocturnal dyspnea present
C/O Bilateral pedal edema below knees , facial puffiness and periorbital edema since 8 days , insidious onset, gradually progressive in nature , no diurnal variation, pitting type I.
C/o decreased urine output and decreased appetite since 5days
No C/o chest pain, palpitations, profuse sweating,
No c/o fever, cold, cough, nausea, vomiting, loose stools.
His daily routine is waking up at 6: 00 am, breakfast as idli/upma at 8:00 am . He used to have his lunch as rice and curry , sambhar/rasam at 1: 00 pm .He usually haves his dinner as chapati/upma/rice and curry at 8:00pm and goes to bed by 9:00 pm.The patient used to lead a normal life before this 15days .
HISTORY OF PAST ILLNESS:
K/c/o asthma since 10yrs -on medication
N/K/C/O DM, CAD, CVD, Thyroid, epilepsy
K/C/O HTN 6 yrs ago and used medication for 3 yrs and stopped as BP was under control
H/O TB 30 yrs ago
SURGICAL HISTORY: -
FAMILY HISTORY:
N/K/C/O DM, HTN, Asthma, Epilepsy, CAD, CVD, TB, Thyroid
PERSONAL HISTORY:
Married
Shop keeper by occupation
Diet: Mixed
Appetite: decreased
Sleep: adequate
Urine output decreased
Bowel movements: Regular
Addictions: Alcohol occasionally
Allergies: no known
GENERAL EXAMINATION:
Patient is drowsy due to sedation, coherent to time , place, person.
Ht: 155cm Wt: 58 kg
Pallor: present
Icterus: absent
Clubbing: absent
Cyanosis: absent
Koilonychia: absent
Lymphadenopathy: absent
Post intubation vitals: Vitals: Temp: 98 F
BP: 90/60 mmHg
PR: 102 bpm
RR: 15 cpm ACMV mode
SpO2: 100% at 5 litre O2
GRBS: 126 mg%
SYSTEMIC EXAMINATION:
RS:
Orthopnea +
Paroxysmal nocturnal dyspnoea +
wheeze +
Central position of trachea
NVBS +
CVS:
S1 S2 heard
No murmurs
No thrills
ABDOMEN:
Shape of abdomen: mildly distended
No tenderness
No palpable mass
No bruits
Liver and spleen- not palpable
Bowel sounds heard
CNS:
drowsy but arousable
no neck stiffness
kernig's sign negative
cranial nerves: normal
motor - intact
sensory - intact
Glasgow scale E2V2M2 = 6/15
MUSCULOSKELETAL SYSTEM: normal
SKIN: normal
ENT: normal
TOOTH & ORAL CAVITY: normal
PHYSICAL EXAMINATION:
muscle wasting++
PROVISIONAL DIAGNOSIS:
Altered sensorium ? AKI ??
HEART FAILURE(ET 51%)
ANAEMIA
INVESTIGATIONS:
2-12-23
RFT raised urea, creatinine, uric acid, phosphorus,
V
ABG
TROPONIN ↑
BLOOD UREA ↑↑
S. Creatinine ↑ ↑
potassium ↑
blood sugar↑
LFT: AST, Alkaline phosphatase, total proteins↑
RFT: Urea, creatinine, phosphorus, potassium ↑
USG
ECG: Left ventricular hypertrophy
MRI Brain plain
The patient may be having (from investigations)
UREMIC ENCEPHALOPATHY
AKI ON CKD
HEART FAILURE EF 51%
Anemia secondary to CKD
TREATMENT:
intubated i/v/o respiratory failure & low GCS
IV fluids NS @50ml/hr
Ryles feeds water 50ml 2hrly milk 100ml 3hrly
Inj. midazolam 30ml= Inj. Fentanyl
Inj. Noradrenaline 2amp
Inj. Piptaz 2.25ml IV/TID
ET Tube suction 2hrly
chest physiotherapy
position change 2hrly
monitor vitals hrly
Tab. Aspirin
Tab. atorvastatin
3-12-23
APTT
PT
Hemogram: low HB , lymphocytes, eosinophils, PCV, RBC count
raised total count, neutrophils
BT& CT
ABG
RFT: Raised urea, creatinine
ECG
The patient may be having (from investigations)
UREMIC ENCEPHALOPATHY
AKI ON CKD
HEART FAILURE EF 51%
Anemia secondary to CKD
TREATMENT:
intubated i/v/o respiratory failure & low GCS
IV fluids NS @50ml/hr
Ryles feeds water 50ml 2hrly milk 100ml 3hrly
Inj. midazolam 30mg+ Inj. Fentanyl 200mcg @16mg/hr
Inj. Piptaz 2.25gm IV/TID
ET Tube and oral suction hrly
Tab. Nodosis 500mg
chest physiotherapy
position change 2hrly
monitor vitals hrly
Tab. ecosprin 75mg RT/OD
Tab. atorvastatin 20mg
4-12-23
2D ECHO:
- No RWMA, paradoxical IVS
- trivial MR, Mild AR
- mild to moderate TR with PAH
- Sclerotic AV, no AS/MS, IAS- intact
- EF= 51 RVSP2 48mmHg
- Good LV systolic function
- diastolic dysfunction
- mild PE(+)
- IVC size 1.20cm collapsing
ABG
Hemogram: low HB , lymphocytes, PCV, RBC count
raised total count, neutrophils
RFT :Urea, creatinine raised
ECG
The patient may be having (from investigations)
UREMIC ENCEPHALOPATHY ??
AKI ON CKD
HEART FAILURE EF 51%
Anemia secondary to CKD
TREATMENT:
intubated i/v/o respiratory failure & low GCS
IV fluids NS @50ml/hr
Ryles feeds water 50ml 2hrly ,milk 100ml 3hrly
Inj. midazolam 30mg+ Inj. Fentanyl
Tab. Nodosis 1gm
Inj. Piptaz 2.25ml IV/TID
ET Tube and oral suction hrly
chest physiotherapy
position change 2hrly
monitor vitals 4 hrly
I/O charting
Tab. ecosprin 75mg
Tab. atorvastatin 20mg
Inj. lasix 40mg
Inj.KCl 40mcg in 500ml/NS
5-12-23
ABG
ECG
The patient may be having (from investigations)
UREMIC ENCEPHALOPATHY ??
AKI ON CKD
HEART FAILURE EF 51%
Anemia secondary to CKD?
TREATMENT:
intubated i/v/o respiratory failure & low GCS
IV fluids NS & DNS@50ml/hr
Ryles feeds water 50ml 2hrly ,milk 100ml 3hrly
Inj. Piptaz 2.25ml IV/TID
Inj. sodium bicarbonate 20ml/IV/TID
ET Tube and oral suction 2hrly
monitor vitals hrly
I/O charting
Tab. ecosprin 75mg
Tab. atorvastatin 20mg
Inj. lasix 40mg
Inj. KCl 40mcg in 500ml/NS
Tab. shelcal ct
Tab. orofer xt
12
6-12-23
Hemogram: low Hb, lymphocytes, eosinophils, PCV, RDC count
RFT: raised urea, Creatinine
ABG
The patient may be having (from investigations)
UREMIC ENCEPHALOPATHY ??
AKI ON CKD
HEART FAILURE EF 51%
Anemia secondary to CKD?
TREATMENT:
intubated i/v/o respiratory failure & low GCS
IV fluids NS & DNS@50ml/hr
Ryles feeds water 50ml 2hrly ,milk 100ml 3hrly
Inj. Piptaz 2.25ml IV/TID
Inj. sodium bicarbonate 20ml/IV/TID
ET Tube and oral suction 2hrly
monitor vitals hrly
position changing 2hrly
I/O charting
Tab. ecosprin 75mg
Tab. atorvastatin 20mg
Inj. lasix 40mg
Inj. KCl 40mcg in 500ml/NS
Tab. shelcal ct
Tab. orofer xt
inj. pantop 40mg
inform sos
References:
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