55 year old with generalised body swelling since 15 days

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Complaints:-

C/o generalised body swelling since 15 days

C/o shortness of breath since 10 days

C/o decreased urine output since 10 days

C/o fever since 2 days

History of presenting illness:-

Patient was apparently asymptomatic 15 days back then noticed generalised body swelling (Anasarca) since then

C/0 shortness of breath since 10 days, insidious in onset, gradually progressive, from grade I to grade III, orthopnea present, No PND

C/o decreased urine output since 10 days, burning micturition present,

No C/o cough, nausea, vomiting , loose stools

Past history:-

K/C/O DM since 6 years and is on inj.Human Actripid Insulin 10U--10U--10U

K/C/O HTN since 1 year and is on Tab.amlodipine 10mg OD

k/c/o CKD since 1 year and is on conservative management.

N/K/C/O CAD, CVD, Thyroid disorders, epilepsy

Personal history:-

Diet :- 

Addictions:- stopped smoking 5 years ago.

Used to smoke beedi 2 packs/day

Used to drink alcohol occasionally,stopped drinking 5 years ago

Sleep:- adequate

Bowel and bladder movements:- decreased urine output since 10 days,bowel movements regular

Family history:- not significant

GENERAL EXAMINATION: 

Patient is drowsy due to sedation, coherent to time , place, person.

Pallor: present 

Icterus: present

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

PR: 102 bpm

RR: 15 cpm 

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: no focal neurological deficits

Provisional diagnosis:- ??CKD secondary to diabetes

Investigations:-

Urea:-87

Creatinine:-6.4

K+:-3.1

Hb:-7.7

TLC:-11099

N/L/E/m:-82/12/0/6

6 hemodialysis were done to this patient

Post dialysis serum urea level was 10mg/dl

Serum creatinine:- 3.8 mg/dl

K+:-3.7 mEq/L

Diagnosis -chronic kidney disease secondary to diabetes(diabetic nephropathy)

Anemia of chronic disease ( secondary to CKD)

Type2 respiratory failure

Treatment:-

Inj.ceftriaxone 1gm IV/BD for 5 days

Inj.piptaz 4gm IV stat followed by 2.25 gm IV TID for 4 days

Inj.clindamycin 600mg IV BD for 4 days

Inj.lasix 50mg IV BD

Inj HAI according to GRBS

Inj.EPO 5000units s/c weekly once

Tab.amlodipibne 5mg po OD

Tab nodosis 500 mg po BD

Intermittent Bipap

Tab.shelcal po OD