60 yr old male with cor Pulmonale and chronic renal failure

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A 60yr old male pt , farmer by occupation came to the op with

c/o intermittent cough with sputum since 6months

c/o Abdominal distension since 20days

c/o bilateral swelling of lower limbs since 15days

c/o shortness of breath since 15days

c/o indigestion since 15days

Pt was apparently asymptomatic 6months ago, then he developed cough with sputum, intermittent in nature ,sputum small in quantity, non foul smelling , non blood tinged, associated with wheeze at night time.

c/o abdominal distension since 20days which aggravated on eating food, associated with indigestion.No loss of appetite.

c/o bilateral pedal edema since 15 days , which is pitting type,insidious in onset, gradually progressive initially upto ankles then progressed upwards till knee

No h/o fever , headache , burning micturition , guiddiness ,hematuria or decreased urine output

Shortness of breath since 15days aggravated on lying down and walking , relieved on sitting .SOB is not associated with palpitations.

Past history :

Similar complaints of shortness of breath pedal edema and peri orbital edema 40years back for which he was admitted in Gandhi hospital where catheter was introduced through femoral artery and he was advised by the doctors to go to USA for cardiac surgery as told by the patient(records not available)

Pt is on inhalational bronchodilators in v/o ??bronchial asthma (pt c/o wheeze during night times since 6months)

No h/o occupational exposure and no factories around his surroundings 

Not a k/c/o DM, HTN, Epilepsy,any other systemic illness

Personal history :

Normal appetite

Mixed diet

Bowel and bladder regular

No alcohol abuse and not a smoker 

General examination :

Pt is C/C/C, moderately built and nourished.

B/l pedal edema present



No Pallor, Icterus , Clubbing, Cyanosis,Generalised lymphadenopathy.

Vitals:

Afebrile

Pulse : 82 bpm, irregularly irregular,low volume

Bp : 140/100 mm 

Resp rate : 35cpm

Systemic examination :

Resp system :

BLAE present, no decreased breath sounds

Chest is bilaterally symmetrical

bilateral  end expiratory wheeze and coarse crepts heard diffusely in all quadrants predominantly over rt sacpular region

GI system:

Per abdomen soft 

Abdomen is distended

Umbilicus is everted

No scars , sinuses , no engorged veins 

On palpation no local rise of temperature and tenderness, no organomegaly

Shifting dullness present



CVS:

S1,S2 heard, no murmurs

CNS: 

No focal neurological deficits

Investigations :

ECG:



Chest x ray



2D echo:



Laboratory investigations :

CBP:



ABG:



RFT



LFT



CUE



Serum electrolytes :



Blood urea



Serum creatinine



USG Abdomen



Provisional diagnosis :

Cor Pulmonale with Chronic Renal failure

Treatment :

1)Inj Lasix 40mg IV BD

2)Tab Ramipril 5mg PO OD

3)Tab Cardivas 3.125mg PO OD

4)Tab Nodosis 550mg PO OD

5) Nebulisation with Budecort 2respules and Duolin 2 respules 

6)Fluid restriction <1.5lt/day and salt restriction <2gm/day

Day 1:

Pt c/o SOB grade 4

Vitals:

1)Afebrile

Bp:90/60 mm hg

Pulse:78 bpm, irregularly irregular,low volume

CVS: S1,S2 heard,no murmurs

Resp : b/l diffuse coarse crepts heard predominantly over rt sacpular region and wheeze present

GI system: soft , non tender, distension present

Treatment :

1) Fluid restriction <1.5lt/day and salt restriction <2gm/day

2)Tab Ramipril 5mg PO OD

3)Tab Cardivas 3.125mg PO OD

4) Nebulisation with Ipravent 2respules and Budecort 2respules

5)Tab Nodosis 550mg OD

6)Tab Azithromycin 500mg OD

7)Inj Dobutamine 1amp in 50 ml NS

Day 2:

Pt c/o abdominal discomfort , cough with sputum

Ascitic tap is done for diagnostic purpose

Vitals :

Afebrile

Bp: 90/50mm hg

Pulse : 50bpm irregularly irregular,low volume

CVS::S1,S2 heard, no murmurs

Resp: BLAE present, b/l coarse crepts heard diffusely in all quadrants predominantly over rt sacpular region and wheeze present

GI system :

P/A : soft and non tender

Treatment :

1) Tab Augmentin 625mg PO BD

2) Tab Azithromycin 500mg PO OD

3)Inj Lasix 20mg IV BD

4) Nebulisation with Ipravent 2respules 

5)Tab Cardivas 3.125mg PO OD

6)Tab Nodosis 550mg OD

7) Fluid restriction <1.5lt/day and salt intake <2gm/day

8)Inj Dobutamine 1amp in 50ml NS @ 10ml /hr