70 year FEMALE PATIENT , STAGE IV CLD, ACUTE ON CKD, HEART FAILURE WITH PRESERVED EJECTION FRACTION

Title - Stage IV CLD, ACUTE ON CKD , HEART FAILURE WITH PRESERVED EJECTION FRACTION

A 70 year old female patient was brought to casuality with
C/o Anuria since 1 day
        Decreased urine output since 10 days
        Generalised weakness 
        Nausea, Vomiting since 3 days
        Decreased appetite 
        Constipation since 3 days
        Productive cough since 7 days
        Cold since 7 days
HOPI
70 year old female with recent history of hospital admission for urosepsis and ckd  and 5 sessions od hemodialysis presented to casuality with c/o decreased urine output for the past 10 days that gradually progressed to Anuria (since 1 day) associated with Nausea and vomiting
C/o Constipation since 3 days associated with pain abdomen
Past History 
K/c/o Type 2 DM since 15 years on Inj. HUMAN ACTRAPID INSULIN
K/c/o HTN since 20 years on T.METOPROLOL 50mg
K/c/o Hypothyroidism since 8 months on T. THYROXINE 50mcg
Chronic Kidney Disease since 3 months
Past history ACS-CSD and CABG performed 8 years ago
S/p Left Mastectomy 30 years ago
N/k/c/o Asthma, TB
Family history  - No significant family history
General Physical Examination 
Patient is C/C/C
Pallor present
No Icterus, Cyanosis, Lymphadenopathy,  Edema
Vitals 
Temperature  - Afebrile
PR 98 bpm
RR 26 cpm
BP 90/60 mmHg
SpO2 98%  at 4 liters of O2
GRBS  124 mg%
Sustemic Examination
CVS - S1, S2 heard, No murmurs
RS - BAE present,  No wheeze, dyspnoea
        NVBS present 
P/A -  Obese, Soft, Non tender
           No palpable mass, No organomegaly
           Bowel sounds present
CNS - NFND

Provisional Diagnosis -
1.STAGE 4 CKD secondary to DIABETIC NEPHROPATHY
2.HEART FAILURE with REDUCED EJECTION FRACTION
3.ACUTE ON CKD  secondary to URINARY TRACT INFECTION secondary to ? TRANSITIONAL CELL CARCINOMA OF BLADDER
4. ACS- CAD- TVD S/P CABG (8 YWARS AGO)
5.K/C/O LEFT BREAST CARCINOMA S/P LEFT MASTECTOMY 
LEFT CRT (30 YEARS AGO)
6.HYPOTHYROIDISM; HTN; T2DM
Investigations 
2D echo (11/1/2024)
- Left mild pleural effusion
- Left mild Hydroureteronephrosis
- Right Grade 2 RPD changes
- Minimal Ascites

Treatment 
1. Fluid restriction  <1.5 lt/day
2. Salt restriction  <2gm/day
4. Tab TORSEMIDE 20mg PO/BD
5. TAB THYRONORM 50mcg PO/OD
6. TAB ECOSPRIN AV 75/10/PO/HS
7. INJ. MEROPENEM 50mg IV/OD 
8. TAB OFLOXACIN 300mg PO/OD
9. TAB ISOSORBIDE 5mg PO/OD
10. TAB NICORANDIL 10MG PO/OD
11. TAB MET-XL 12.5MG PO/SOS
12. SYP. CREMAFFIN PLUS 15ML PO/TID
13. SYP. ASCORYL IL 15ML PO/TID
14. INJ. HUMAN ACTRAPID INSULIN SC/TID
15. TAB METALAZONE 5MG PO/OD



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