65y old male with breathlessness since today morning

65 year old male came to opd with chief casualty with chief complaints of breathlessness since today morning. 

HOPI :-
Patient was apparently asymptomatic till today morning then developed difficulty in breathing, initially grade 2 which progressed to grade 4 . 

C/o generalised body swelling since today morning ( Anasarca). 
No c/o chest pain, palpitations, PND

Past history:-
 k/c/o CKD on MHD, since 2 months. 
N/k/c/o HTN, Asthma , DM2. 

Family h/o:- insignificant

General Examination :-
Patient is conscious, coherant and cooperative at the time of admission 
Well oriented with time and space 
Moderately built and moderately nourished
Vitals at admission :- 
Temp - afebrile
BP - 110/70 mmhg
PR- 112 bpm
RR- 18 cpm
Systemic examination:-
CVS - S1S2 heared, no murmurs 
RS- BAE +, 
CNS- NFND
P/A - soft and non tender. 
GRBS- 132 mg/dl

USG:- 
Bilateral grade II RPD changes. 
Bilateral pleural effusion with underlying lung collapse 
Right mild hydronephrosis 
Left moderate hydronephrosis. 

PROVISIONAL DIAGNOSIS :- ACUTE PULMONARY EDEMA ( RESOLVING) CKD ON MHD
HEART FAILURE WITH MIDRANGE EFEF WITH SVT

FINAL DIAGNOSIS :- ACUTE PULMONARY EDEMA
HEART FAILURE WITH MIDRANGE EF
CKD ON MHD STAGE WITH CKD
LEFT UPPER LOBE CONSOLIDATION ? CAP

TREATMENT GIVEN :- 
1) Nebulisation with Ipravent 6th hrly, budecort 12 th hrly. 
2) Fluid restriction< 1.5 lt / day. 
3) Salt restriction < 2g/ day. 
4) Inj. Piptaz 2.25 g IV / TID 
5) Inj. Lasix 40 mg IV BD if SBP >110mmhg.
6) Inj. Pantop 40 mg IV OD BBF
7) Tab. Nodosis 500 mg PO HS 
8) Tab. Orofer -xt PO OD 
9) Tab. Shelcal -CT PO OD
10) Tab Azithromycin 500 mg 
11) Inj. Iron sucrose 200 mg IV in 100 ml NS IV OD
12) Inj. EPO 4000 IU SC once a week 
13) cap. Bio D3 PO once a week 
14) Tab. Mucinac 600 mg PO /TID
15) Monitor vitals BP, PR, RR, SpO2, temp, every 2 nd hrly. 
16) Strict input and output charting 
17) Intermittent CPAP. 
18) Tab. Levofloxacin 750 mg / PO/ OD. 


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