Daily routine:
- He is a farmer by occupation, working from 25 years
- Patient wakes up at 5:00 am in the morning
- He helps in household chores, has breakfast at around 8 am and goes to farm
- He eats lunch - rice with dal/curry at around 1:00 pm
- He has a cup of tea at around 5:00 pm
- He finishes his work by 6:00 pm
- He finishes his dinner at around 9:00 pm
- Goes to bed at around 10:00 pm
CHIEF COMPLAINTS:
Patient came with complaints of
1. Cough with sputum since 10 months
2. SOB grade II-II (MMRC) since 10 days.
- B/L grade 2
3. pedal edema since 3 days
HOPI-
Patient was apparently asymptomatic 10 months ago then he had cough with white mucoid, non blood stained, copious sputum.
2 months ago then he developed fever which was insidious in onset, high grade for 2 days for which he went to a local RMP at Miryalagudem, where he was given medication and the fever reduced.
Since then the patient gives history of intermittent episodes of fever for which he took medication from the same RMP.
Patient developed low back ache 2 months ago, for which he went to a local private hospital in Miryalagudem where CT scan was done and he found out that there was radiculopathy and was given medication for the same.
Later,
May 5 2023
He developed chest pain radiating to back so he went to Miryalagudem hospital where he also got an ultrasound scan done which showed deranged parameters and was referred to Gandhi hospital
May 6 2023
Patient went to Gandhi hospital with c/o chest pain radiating to back , blurring of vision and also presented in a state of hypertensive emergency with BP of 220/150 mm hg. Inj. Labetalol was given.
Investigations on 10/5/23 - in Gandhi hospital -day of discharge
Hb: 9.6 gm/dl
TLC: 8,250
Urea: 117
Creatinine: 5.98
Na: 138
K:4.8
Cl:98
Total bilirubin 1.16
Direct bilirubin 0.7
AST 10
ALT. 28
ALP. 88
Total protein 6.73
Troponin I - negative
ABG -
pH -- 7.4
PCO2 - 22.4
PO2 - 100
HCO3 - 14
Anion gap - 9.2
ECG - ST depression in Lead I V1 V5, LVH
USG -
- B/l kidney raised S/E
- Liver raised S/E
- Mild pleural effusion
2D ECHO
Lvh + RWMA +
No PE/PAH/ MS/AS
Mild MR , No TR
Fair LV systolic function
EF - 58 %
At the time of discharge, they planned for CAG, asked to avoid nephrotoxic drugs and planned for dialysis.
He was discharged with the following advice -
1) T. Metoprolol 25 mg BD
2) P. Amlodipine 10 mg OD
3) T. NaHCO3 500mg PO/TID
5) T. Aspirin mg OD
6) T. Atorvastatin 10 mg
7) T-clopidogrel 75mg OD
8) T. azithromycin 500 mg OD
9) T. PCM 650 mg po/tid
Later, 20 days ago he went to Miryalagudem hospital again with c/o chest pain, cough with sputum and back pain where he was diagnosed with TB and was advised ATT and the patient started to take them.
HRCT scan on 17/5/23
- cough with sputum on and off since 10 months
- low backache since 2 months
- SOB grade II-II (MMRC) since 10 days.
Pallor present
11/7/23
13/7/23
Chest xray on 12/7/23
Review usg -
18/7/2023
- B/L grade 2 pedal edema since 3 days
PAST HISTORY -
K/C/O Hypertension since 2 months
K/C/O TB since 2 months on ATT
Not a K/C/O DM II, Thyroid disorders, epilepsy
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bladder: Normal
Bowel : Normal
Patient is an alcoholic since 30 years- 250 ml/ day
- Beedi smoker (2 packs / day) for about 15 years. Stopped 2 months back.
No known allergies
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative
Patient was examined in well lit room after taking well informed consent.
Patient is moderately built and moderately nourished.
Edema (on admission)- B/L Grade II pitting type
No icterus/cyanosis/clubbing/Generalized lymphadenopathy
VITALS ON ADMISSION -
Temp: Afebrile
PR: 78 bpm
RR: 20 cpm
BP: 170/100mmHg
Spo2: 95% @RA
GRBS: 111 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1 S2 heard, No murmurs
RS: BAE+
P/A: Distended, non tender
Umbilicus - Central
No engorged veins, scars or sinuses
1. Autonomic function: Normal
2. CNS examination:
Pupils -B/L NSRL
GCS - E4V5M6
Cranial nerves - NAD
MOTOR SYSTEM :
Rt Left
Bulk: N. N
Tone: Rt Left
UL. N N
LL. N N
Deep tendon reflexes:
Biceps: +2 +2
Triceps: +2 +2
Supinator: +2 +2
Knee: +2. +2
Ankle: +2 +2
Plantar: flexor B/L
Sensory system : Intact
PROVISIONAL DIAGNOSIS:
CHRONIC KIDNEY DISEASE
HYPERTENSIVE URGENCY
HFmEF
K/C/O Hypertension since 2 months
Left eye Grade IV Hypertensive retinopathy with maculopathy? Papilledema
K/C/O TB Since 2months on ATT
1st session hemodialysis on 12/7/23
One packed cells Blood transfusion done on 13/7/23
Investigations:
Chest xray on 13/7/23
TREATMENT:
1)Fluid restriction <lit/day
2)salt restriction <2g/day
3)INJ ERYTROPOETIN 4000 IU sc/ once weekly
4)TAB.ISONIAZID 5mg/kg/day PO/OD,BBF
265mg
5)TAB. RIFAMPICIN - 10mg/kg/ day PO/OD BBF 530 mg
6)TAB. ETHAMBUTOL 15mg/kg / po thrice weekly 785mg
7)TAB. BENADON 40mg PO/OD
8) T-NICARDIA 20mg po/TID
9)TAB.ARKAMINE 0.1mg Po/TID
10)TAB. MINIPRESS-XL 5mg po/BD
11)TAB.LABETALOL 100mg Po/OD
12) TAB.NODOSIS 500mg pо/BD
13) TAB. LASIX 40mg PO/BD
14)TAB. OROFER -XT Po/OD
15)TAB. SHELCAL-CT PO/OD
16) T. MET-XL 50mg po/OD
17) TAB SIVLAMER 400 mg Po/TID
PULMONOLOGY REFERRAL DONE I/V/O TB FOR ATT - on 12/7/23
ADVICE -
1. Switch to continuation phase of ATT - 4 HRE
2. TAB.ISONIAZID 5mg/kg/day PO/OD,BBF
265mg
TAB. RIFAMPICIN - 10mg/kg/ day PO/OD BBF 530 m
TAB. ETHAMBUTOL 15mg/kg / po thrice weekly 785mg
3.TAB. BENADON 40mg PO/OD
OPHTHALMOLOGY REFERRAL- 14/7/23
I/V/O Raised ICT and hypertensive retinopathy
- Right eye senile mature cataract
- Left eye disc edema under evaluation -
Grade IV hypertensive retinopathy with maculopathy ? Papilledema
15/7/2023
S:
Dry cough present
O:
Patient is conscious, coherent and cooperative
Temp-98.7F
PR-82 bpm
BP-160/110 mm hg
RR-22 cpm
SPO2-98% @RA
RS- BAE +,
crepts in B/L IAA
CVS-S1,S2+, Raised JVP
P/A- Soft, NT
CNS- NFD
A:
CHRONIC KIDNEY DISEASE WITH
HYPERTENSIVE URGENCY
HFmEF WITH
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHS
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 300MG PO OD BBF
TAB RIFAMPICIN 600MG PO OD BBF
TAB ETHAMBUTOL 800MG PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO TID
TAB ARKAMINE 0.1MG PO TID
TAB MINIPRESS XL 5MG PO BD
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO BD
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB MET-XL 50MG PO OD
2nd session hemodialysis on 15/7/23
Sputum culture and sensitivity:
1. Grade I RPD changes in Right kidney
2. Grade I RPD changes in Left kidney and simple renal cortical cysts largest measuring
2 x 2 cm
16.6.23
17.6.23
Sputum Positive for Rifampicin Sensitive TB
MRI BRAIN- PLAIN
ECG-
S
Cough decreased.
O
Patient is conscious, coherent and cooperative
Temp-98.7F
PR-78 bpm
BP-160/90 mm hg
RR-20 cpm
SPO2-98% @RA
RS- BAE + NVBS
CVS-S1,S2
P/A- Soft, nontender
CNS- NFD
A
CHRONIC KIDNEY DISEASE WITH HFmEF WITH HYPERTENSIVE EMERGENCY
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHs
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 300MG PO OD BBF
TAB RIFAMPICIN 600MG PO OD BBF
TAB ETHAMBUTOL 800MG PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO TID
TAB ARKAMINE 0.2MG PO TID
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO BD
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB LABETALOL 100MG PO TID
PULMONOLOGY REVIEW REFERRAL
1. ATT under NTEP guidelines
2. TAB ISONIAZID 5 mg/kg PO OD BBF
TAB RIFAMPICIN 10mg/kg PO OD BBF
TAB ETHAMBUTOL 15mg/kg PO OD THRICE WEEKLY
TAB PYRIZANAMIDE 25mg/kg PO OD THRICE WEEKLY
2D ECHO
18/7/2023
S
Cough with sputum present
C/o giddiness
O
Patient is conscious, coherent and cooperative
Temp-97.8F
PR-68 bpm
BP-190/110 mm hg
RR-20 cpm
SPO2-98% @RA
RS- BAE + NVBS
CVS-S1,S2
P/A- Soft, nontender
CNS- NFD
A
CHRONIC KIDNEY DISEASE WITH HFmEF WITH HYPERTENSIVE EMERGENCY
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHs
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 5mg/kg PO OD BBF
TAB RIFAMPICIN 10mg/kg PO OD BBF
TAB ETHAMBUTOL 15mg/kg PO OD THRICE WEEKLY
TAB PYRIZANAMIDE 25mg/kg PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO OD (AFTERNOON)
TAB NICRADIA 40 MG PO BD (MORNING AND NIGHT)
TAB ARKAMINE 0.2MG PO TID
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO TID
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB LABETALOL 100MG PO TID
19/7/2023
S
Cough with sputum present.
O
Patient is conscious, coherent and cooperative
Afebrile
PR-78 bpm
BP-180/110 mm hg
RR-18 cpm
SPO2-98% @RA
RS- BAE + NVBS
CVS-S1,S2
P/A- Soft, nontender
CNS- NFD
A
CHRONIC KIDNEY DISEASE WITH HFmEF WITH Malignant hypertension with
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHs (sputum positive TB)
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 5mg/kg PO OD BBF
TAB RIFAMPICIN 10mg/kg PO OD BBF
TAB ETHAMBUTOL 15mg/kg PO OD THRICE WEEKLY
TAB PYRIZANAMIDE 25mg/kg PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO OD (AFTERNOON)
TAB NICRADIA 40 MG PO BD (MORNING AND NIGHT)
TAB ARKAMINE 0.2MG PO TID
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO TID
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB LABETALOL 100MG PO TID
TAB PRAZOSIN 5 MG PO BD
20/7/2023
S
Cough with sputum present.
O
Patient is conscious, coherent and cooperative
Afebrile
PR-90 bpm
BP-160/90 mm hg
RR-17 cpm
SPO2-99% @RA
RS- BAE + NVBS
CVS-S1,S2
P/A- Soft, nontender
CNS- NFD
A
CHRONIC KIDNEY DISEASE WITH HFmEF WITH Malignant hypertension with
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHs (sputum positive TB)
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 5mg/kg PO OD BBF
TAB RIFAMPICIN 10mg/kg PO OD BBF
TAB ETHAMBUTOL 15mg/kg PO OD THRICE WEEKLY
TAB PYRIZANAMIDE 25mg/kg PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO OD (AFTERNOON)
TAB NICRADIA 40 MG PO BD (MORNING AND NIGHT)
TAB ARKAMINE 0.2MG PO TID
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO TID
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB LABETALOL 100MG PO TID
TAB PRAZOSIN 5 MG PO BD
RFT -
21/7/2023
S
Cough with sputum present.
O
Patient is conscious, coherent and cooperative
Afebrile
PR-88 bpm
BP-150/90 mm hg
RR-17 cpm
SPO2-98% @RA
RS- BAE + NVBS
CVS-S1,S2
P/A- Soft, nontender
CNS- NFD
A
CHRONIC KIDNEY DISEASE WITH HFmEF WITH Malignant hypertension with
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHs (sputum positive TB)
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 5mg/kg PO OD BBF
TAB ETHAMBUTOL 15mg/kg PO OD THRICE WEEKLY
TAB PYRIZANAMIDE 25mg/kg PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO OD (AFTERNOON)
TAB NICRADIA 40 MG PO BD (MORNING AND NIGHT)
TAB ARKAMINE 0.2MG PO TID
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO TID
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB LABETALOL 100MG PO TID
TAB PRAZOSIN 5 MG PO BD
22/7/2023
S
Cough with sputum present.
O
Patient is conscious, coherent and cooperative
Afebrile
PR-98 bpm
BP-150/90 mm hg
RR-18 cpm
SPO2-989% @RA
RS- BAE + NVBS
CVS-S1,S2
P/A- Soft, nontender
CNS- NFD
A
CHRONIC KIDNEY DISEASE WITH HFmEF WITH Malignant hypertension with
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHs (sputum positive TB)
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 5mg/kg PO OD BBF
TAB ETHAMBUTOL 15mg/kg PO OD THRICE WEEKLY
TAB PYRIZANAMIDE 25mg/kg PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO OD (AFTERNOON)
TAB NICRADIA 40 MG PO BD (MORNING AND NIGHT)
TAB ARKAMINE 0.2MG PO TID
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO TID
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB LABETALOL 100MG PO TID
TAB PRAZOSIN 5 MG PO BD
23/7/2023
S
Cough with sputum present.
O
Patient is conscious, coherent and cooperative
Afebrile
PR-98 bpm
BP-140/90 mm hg
RR-18 cpm
SPO2-989% @RA
RS- BAE + NVBS
CVS-S1,S2
P/A- Soft, nontender
CNS- NFD
A
CHRONIC KIDNEY DISEASE WITH HFmEF WITH Malignant hypertension with
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHs (sputum positive TB)
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 5mg/kg PO OD BBF
TAB ETHAMBUTOL 15mg/kg PO OD THRICE WEEKLY
TAB PYRIZANAMIDE 25mg/kg PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO OD (AFTERNOON)
TAB NICRADIA 40 MG PO BD (MORNING AND NIGHT)
TAB ARKAMINE 0.2MG PO TID
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO TID
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB LABETALOL 100MG PO TID
TAB PRAZOSIN 5 MG PO BD
22/7/2023
S
Cough with sputum present.
O
Patient is conscious, coherent and cooperative
Afebrile
PR-98 bpm
BP-150/90 mm hg
RR-18 cpm
SPO2-989% @RA
RS- BAE + NVBS
CVS-S1,S2
P/A- Soft, nontender
CNS- NFD
A
CHRONIC KIDNEY DISEASE WITH HFmEF WITH Malignant hypertension with
LEFT EYE- GRADE IV HYPERTENSIVE RETINOPATHY WITH MACULOPATHY WITH PAPILLEDEMA
RIGHT EYE - MATURE SENILE CATARACT
K/C/O HTN SINCE 2 MONTHS
K/C/O TB ON ATT SINCE 2 MONTHs (sputum positive TB)
P
FLUID RESTRICTION <1LITRE/DAY
SALT RESTRICTION<2G/DAY
TAB ERYTHROPOIETIN 4000 IU SC ONCE WEEKLY
TAB ISONIAZID 5mg/kg PO OD BBF
TAB ETHAMBUTOL 15mg/kg PO OD THRICE WEEKLY
TAB PYRIZANAMIDE 25mg/kg PO OD THRICE WEEKLY
TAB BENADON 40MG PO OD
TAB NICARDIA 20MG PO OD (AFTERNOON)
TAB NICRADIA 40 MG PO BD (MORNING AND NIGHT)
TAB ARKAMINE 0.2MG PO TID
TAB SIVLAMER 400MG PO TID
TAB NODOSIS 500MG PO BD
TAB LASIX 40MG PO TID
TAB OROFER XT PO OD
TAB SHELCAL CT PO OD
TAB LABETALOL 100MG PO TID
TAB PRAZOSIN 5 MG PO BD
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