60 year old male with complaints of vomitings and facial puffiness
GENERAL MEDICINE CASE
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CASE:
A 60 yr old male , resident of suryapet, driver by occupation , came with complaints of
1) Facial puffiness and vomitings since 5 days
2) B/l pedal edema ( pitting ) since 4 days
HISTORY OF PRESENT ILLNESS:-
He was apparently asymptomatic 10 yrs ago , then he developed blurring of vision for which he went local hospital and was diagnosed with Hypertension and diabetes mellitus type 2 and started on treatment (irregular).
3 MONTHS BACK ,he complaints of vomitings -5 episodes ( food particles as content) ,non bilious ,non projectile, so he went to a local hospital in khammam and was told to have kidney infection and took medication for 1 week .
AT PRESENT , he complaints of increased urine Nocturia since 6 days ,
Vomitings since 4 days
Facial puffiness since 5 days and
B/l pedal edema (pitting type) since 4 days
Loss of appetite+
Dull with slow speech since 1 week
SOB (grade2) ,with cough on walking for a short while.
PAST HISTORY:-
K/c/o Type2 DM and HTN since 10 years on irregular medication.
Visual acuity--
Right eye -- complete blind
Left eye-- Hand movements+
PERSONAL HISTORY
Appetite- decreased
Diet- mixed
Bowel movement- Regular
Alcoholic +
Non smoker
On examination:
Pt is Concious coherent and cooperative
No Pallor,Icterus,Cyanosis, clubbing,Lymphadenopathy
B/L pedal Edema(pitting type) present
VITALS ON ADMISSION:-
TEMPERATURE- Afebrile
BP:- 190/110 mmHg
PR-- 91 BPM
RR- 21 cpm
Spo2:- 97% on RA
Systemic examination:-
PER ABDOMEN: soft, non tender
CVS: S1S2 heard
RS: BAE +, NVBS+
CNS: NAD
DIAGNOSIS:-
Diabetic nephropathy? Ckd?
Uremic encephalopathy?
With blindness due to DM and HTN
TREATMENT:-
One haemodyalysis on 19-1-22
4 haemodyalysis done further on 2nd , 4th, 7th and 8th day of admission
Day 1
1) INJ. LASIX 40 MG IV /BD
2) Tab. NICARDIA 10MG PO/BD
3) INJ. HAI ACCORDING TO SLIDING SCALE.
4) TAB. NODOSIS 550 MG PO/BD
5) TAB.SHELCAL PO/OD
6) INJ. ZOFER 4 MG IV /OD
7) INJ. PAN 40 MG/IV/OD
8) INJ. PIPTAZ 2.25 GM IV /TID
9) MONITOR VITALS AND INFORM SOS.
Day2
1. Inj LASIX 40mg IV BD
2. Tab NICARDIA 40mg PO BD
3. Tab NODOSIS 550 mg PO BD
4. Tab SHELCAL PO OD
5. Inj ZOFER 4mg IV OD
6. Inj PAN 40 mg IV OD
7. Inj PIPTAZ 2.25 mg IV TID
Day 3
1.inj LASIX 40mg IV TID
2. inj ZOFER 4mg IV OD
3. inj PAN 40mg IV OD
4. Tab NICARDIA 10mg PO BD
5. Tab NODOSIS 550mg PO BD
6. Inj PIPTAZ 2.25mg IV TID
Day 4
1. Inj LASIX 40mg
2. Inj ZOFER 4mg
3. Inj PAN 40mg
4. Tab NICARDIA 10mg
5. Tab NODOSIS 550mg
6. Tab PIPTAZ 2.25mg
7. ERYTHROPOIETIN 4000 IU
Day 5
1. Inj Lasix 40mg IV/TID
2. Inj HAI at 8am-2pm-8pm
3. Inj Zofer 4mg IV/OD
4. Inj Pan 40mg IV/OD(3BF)
5. Tab. Nicardia 10mg PO/BD
6. Tab.Nodors 550mg PO/BD
7. Monitor vitals
8. Inj Erythropoietin
9. Inj Piptaz 2.25mg IV/TID
Day 6
1. Inj LASIX BD
2. Inj ZOFER OD
3. Tab PAN 40 OD
4. Tab NICARDIA BD
5. Tab NODOSIS BD
6. Inj PIPTAZ BD
Day 7
1. Inj LASIX 40mg
2. Inj PAN 4mg
3. Inj ZOFER 40mg
4. Tab NICARDIA 10mg
5. Tab NODOSIS 500mg
6. Inj PIPTAZ 2.25mg
Day 8
1. T- LASIX40mg |PO|TID
2. T PAN 40mg PO OD
3. T.NICARDIA 10 mg BD
4. OROFER10 mg XT OD
5. T. NODOSIS 500mg BD
6. SHELCAL CT PO OD
7. Inj. Erythropocitin 4000 tu/se/op
8. Inj. PIPTAZ 2.25 mg
