55year old male with decreased urine output and pedal edema

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A 55 year old male came to the casuality with cheif complaints of

Cheif complaints:

-decreased urine output since 3days

- pedal edema and Upper limb edema since 3days

- fever since 1day


History of presenting illness:

Patient was apparently asymptomatic 3days ago, later he developed pedal edema, Upper limb edema decreased urine output since 3days. Fever since 1day, low grade not associated with chills and rigors

No c/o burning micturition, vomitings, loose stools, cough, SOB, cold

No c/o rashes, mosquito bites

No c/o generalised body pains or myalgia

Past history:

K/c/o DM since 10yrs 

K/c/o HTN since 2yrs

H/o Pulmonary TB 12yrs ago (taken treatment for 6months)

H/o PSVT- Adenosine- S/P RFA 4yrs ago

H/o old CVA- B/L thalamocapsular infarcts 2years ago

Personal history-

Diet- mixed

Appetite - normal

Sleep- Adequate 

Bowl and bladder movements- c/o constipation- hard stools, decreased 

Habits- drinks alcohol weekly twice 

General examination:

Patient is conscious, coherent and cooperative 

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy 

Pedal edema+ 

Upper limb edema+





Vitals on admission:

Bp- 150/70mmHg

Pulse- 112bpm

RR- 24cpm

Temp- 98

Spo2- 99@RA

Grbs- 55

Systemic examination:

CVS- S1 S2+

RS- BAE+, diffuse wheeze, crepts+ in IAA, ISA, IMA

CNS - NAD

P/A- soft, non tender




Investigations:

Day 1

Abg on admission:



 Chest X ray

USG












Day 2 Investigations










Day 3









Day 4










Day 5



Day 6

2:00am
He had sudden onset of sweating and palpitations 
Grbs 121mg/dl
BP-160/90 
PR-112
And was arrested


ECG showing pulseless electrical activity 

CPR was continued


Patient was Intubated and connected to MV

ABG @3:00am


ABG at 2pm






ABG @8pm


Day 7
Abg @2:00am


Abg @ 6:00am






                                   Diagnosis:
Acute exacerbation of COPD with Type 2 Respiratory failure secondary to COPD? Post TB sequalae
AGN on CKD (diabetic nephropathy)
B/L Pleural effusion with ? Community acquired Pneumonia ? Reactivation KOCH's
k/c/o Pulmonary Tb 12years ago (used ATT 12yrs ago and 6months ago- emperically)
H/o PSVT- Adenosine- S/P RFA 4yrs ago
H/o old CVA- B/L thalamocapsular infarcts 2years ago
k/c/o DM since 10yrs
k/c/o Htn since 2yrs
Post CPR status with ?Hypoxic brain injury

 Treatment

Day 1

1. IVF NS@ Urine output 30ml/hr

2.INJ LASIX 40mg IV/BDq

3. INJ PIPTAZ 4.5mg IV STAT 

4. INJ HAI s/c

5. Tab Cilnidpine 10mg  PO/OD

6. Tab MET XL PO/OD

7. Tab Azithromycin 500mg PO/OD

8. Neb with doulin and budecot

Day 2

1. IVF NS@ Urine output 30ml/hr- stop

2.INJ LASIX 40mg IV/BD

3. INJ PIPTAZ 2.5g IV TID

4. INJ HAI s/c

5. Tab Cilnidpine 10mg PO/OD

6. Tab MET XL PO/OD

7. Tab Azithromycin 500mg PO/OD

8. Neb with doulin and budecot

1st session of HD

Day 3

1. Normal diabetic diet

2.INJ LASIX 40mg IV/BD

3. INJ PIPTAZ 2.5g IV TID

4. INJ HAI s/c

5. Tab Cilnidpine 10mg PO/OD

6. Tab MET XL PO/OD

7. Tab Azithromycin 500mg PO/OD

8. Neb with doulin and budecot

Day 4

1. Normal diabetic diet

2.INJ LASIX 40mg IV/BD

3. INJ PIPTAZ 2.5g IV TID

4. INJ HAI s/c

5. Tab Cilnidpine 10mg PO/OD

6. Tab MET XL PO/OD

7. Tab Azithromycin 500mg PO/OD

8. Neb with doulin and budecot

9. GRBS 2nd hourly 

10. Vitals monitoring 2nd hrly

11. Oral fluid < 2L/day

2nd session of HD 

Day 5

1. Normal diabetic diet

2.INJ LASIX 40mg IV/BD

3. INJ PIPTAZ 2.5g IV TID

4. INJ HAI s/c

5. Tab Cilnidpine 10mg PO/OD

6. Tab MET XL PO/OD

7. Tab Azithromycin 500mg PO/OD

8. Neb with doulin and budecot

9. GRBS 2nd hourly 

10. Vitals monitoring 2nd hrly

11. Oral fluid < 2L/day

Day 6

1. Air bed, frequent change in position

2.INJ PIPTAZ 2.25gm IV TID

3. INJ LEVOFLOXACIN 250mg IV/OD

4. IVF @NS URINE OUTPUT 30ml/hr

5. INJ LASIX 40mg IV/BD (if SBP > 110)

6.INJ HAI s/c acc to grbs

7.Tab Cilnidpine 10mg RT/OD (if SBP >110/80)

8. Tab MET XL 25mg RT/OD (if SBP >110/80)

9.Tab ECOSPRIN AV (75/20) RT/OD

10.Neb with duolin and budecot (4th hrly)

11.Tab Azithromycin 500mg RT/OD

12.RT feeds 200ml milk + 100ml water 4th hrly

13. GRBS 4TH hrly

14. SpO2, BP, PR, monitoring 2nd hrly

Day 7

1. Air bed, frequent change in position

2.INJ PIPTAZ 2.25gm IV TID

3. INJ LEVOFLOXACIN 250mg IV/OD

4. IVF @NS URINE OUTPUT 30ml/hr

5. INJ LASIX 40mg IV/BD (if SBP > 110)

6.INJ HAI s/c acc to grbs

7.Tab Cilnidpine 10mg RT/OD (if SBP >110/80)

8. Tab MET XL 25mg RT/OD (if SBP >110/80)

9.Tab ECOSPRIN AV (75/20) RT/OD

10.Neb with duolin and budecot (4th hrly)

11.Tab Azithromycin 500mg RT/OD

12.RT feeds 200ml milk + 100ml water 4th hrly

13. GRBS 4TH hrly

14. SpO2, BP, PR, monitoring 2nd hrly

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