35year female with heart failure,CRF

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 Case reference:


https://elogformedicalcasebyintern.blogspot.com/2021/12/35-f-with-aki-on-ckd.html



SOAP NOTES


 D WARD


25/2/22


S:

 C/O sob and abdominal distension since last dialysis


O:


Patient was C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema


Vitals at admission:

PR- 80 bpm

BP- 140/80 mmHg

RR- 21 cpm

SpO2- 98%

CVS: S1 S2 +,

RS: B/L AE +

P/A: soft nontender .


Ascitic tap was done on 23/2/22 showing high SAAG high protein


SAAG value - 1.8

Ascitic protein - 3.0


A:

? NSAIDS induced nephropathy

(H/o HTN since 2 months)

 High SAAG high protein secondary to heart failure

Recent hemodialysis:

23/2/22

Hemodialysis since 1 month 2 sessions per week


P :


1. INJ. LASIX 40 mg IV BD

2. INJ PAN 40 mg IV OD 

3. INJ ZOFER 4 mg IV OD

4. INJ erythropoietin 4000 IU SC once weekly

5. MONITOR VITALS

6. Tab OROFER XT PO

 OD

7. Tab SHELCAL PO OD

8 T AMLONG 5 mg PO BD

9. T NICARDIA 20 mg PO OD

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