cardio renal syndrome type2

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

D. Shreeya , 8th sem ,roll no 39



A 50 year old female resident nalgonda ,farmer by occupation has come with chief complaints of 
• Pedal edema  since 15 days 
. SOB since 10days 
.fever since 7days

HISTORY OF PRESENT ILLNESS 
Patient was apparently asymptomatic 3 years back then she developed SOB which grade 2 and pedal edema which is initially at the ankle and then progressed to legs and face with in 10 to 15 days and  causing generalised edema .for which she went to nalgonda hospital and used medications prescribed and the symptoms subsided.

6 months back in jan 2022 she developed the same symptoms and again went to nalgonda hospital and took medications and symptoms subsided.then on routine general examination She was also diagnosed with hypertension and is not on treatment.
Now 15 days back she had developed the same symptoms SOB grade 3 and pedal edema  which was initially at the level of ankleand then became generalised edema and went to nalgonda hospital and since the symptoms were not subsiding they came to Kims.
(First she developed pedal edema which extended and caused generalised edema 
5 days after this she developed SOB grade 3).
She also complains of fever for  days no associated with chills and rigors and she also developed cough since 3 days after treatment started here.

PAST HISTORY 
Hypertensive since 6 months earlier when she was diagnosed took medications for 1 month and then she stopped taking medicine 
Not a k/c/o Diabetes, Epilepsy,  Tuberculosis, thyroid 

TREATMENT HISTORY 
Not significant 

PERSONAL HISTORY 
Daily routine she wake up in the morning 6 am and get fresh up do house work and then cook food and then she will have the break fast and then she goes to farm by 9 am and then  return to home by nearly 5pm and then after some time she will prepare dinner and then she will have the dinner 

Diet-mixed
Appetite-decresed
Bowel and bladder movements -regular
Sleep -decreased/ disturbed
No Addictions 
Mo allergy

GENERAL EXAMINATION 
Patient is conscious, coherent and cooperative 
Well oriented to time ,place, person
Moderately built and nourished 

Pallor-no
Icterus-no
Cyanosis-no
Clubbing-no
Lymphadenopathy -no
Edema-Bilateral pedal edema
Clinical pictures 

VITALS
BP 140/80 mmhg
PR 92bpm
RR 18cpm
TEMP febrile
SP02 97%
GRBS 99mg%SOB since 10days

SYSTEMIC EXAMINATION 
RS : NVBS ,BAE+, crepts 
CVS: S1 S2 +
CNS: NFD
PA: soft, non tender, hepatomegaly 

INVESTIGATIONS
.Serum creatinine-
0.9mg/dl(on 20/7/22)
1.0mg/dl(on19/7/22)
1.8 mg/dl(18/7/22)
2.1mg/dl(16/7/22)
.Blood urea-29mg/dl(20/7/22)
                     42mg/dl(on19/7/22)
                     58mg/dl(18/7/22)
                      65mg/dl(16/7/22)
.T3-0.61ng/ml(normal-0.8 to 1.8)
.T4-10.24micro g/dl
.TSH-2.23micro g/ml
.prothrombin time-18 sec
 INR-1.33
APTT test-35sec
.HIV1/2rapid test-non reactive
HBsAg rapid-negative
.random blood sugar-91mg/dl (16/7/22)
.anti HCV antibodies rapid-non reactive
LIVER FUNCTION TEST
LIPID PROFILE 
CBP
ULTRA SOUND-
Grade 1 RPD changes
Mild ascites
Mild b/l pleural effusion 


PROVISIONAL DIAGNOSIS 
Cardiorenal syndrome (type II)

TREATMENT 
1. Fluid restriction 1.5l/day
2. Salt restrictions <2g/day
3. Inj lasix 40mg TID
4. Tab Dolo 650mg TID
5. Inj Neomol 100ml IV SOS
6. Syrup Ascoryl 10ml TID
7. Inj Monocef IV BD
8. Vital monitoring 8th hourly

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