48yr old patient with CKD

A PAVAN KUMAR ROLL NO. 08



"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box i



January 03, 2022 48 YR OLD PATIENT 


 -This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

-Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". 

-This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

- CKD ward: 48 year old man With DM type 2 diagnosed 10 years back 3 years back - He had lower back ache for which he used NSAIDs, for which he visited a hospital where he was told to have multiple renal cysts And he was even diagnosed with hypertension then At that point his serum creatinine was 1.2mg/dl.

- He was stated on conservative treatment. He was on followup. 

- Post COVID, he didn't pay a visit for followups 3 months back he developed bilateral lower edema Sudden onset dyspnea On visiting the hospital, his serum creatinine also was found to be 9mg/dl Since then he has been on regular Hemodialysis 

HOPI 

- Pt was apparently assymptomatic 20 yrs back then he developed lower back pain for which he visited to hospital and diagnosed with renal calculi for which he used medication for 3 years and underwent surgery later ,

-still his lower back pain didn't subcided so he visited to some rmp and used NSAIDS for 10-15 years ,

-later on 3 years back one day he developed bilateral pedal edema with shortness of breathe.

- he visited to hospital and diagnosed with CKD and HTN and using regular medication with regular followup due covid 19 lockdown he didn't had regular checkups using medication ,

-3 months back when he visited to hospital then he was told to have high creatinine (around 11 ,acc to patient) and need for dialysis intervention ,then he was started on dialysis . 

-He had 2 sessions of dialysis every week VITALS the time of admission: 
 Temp-98.5 
 PR-92bpm 
 RR-26cpm 
 BP-130/70 mmHg 
 Spo2-93@ RA 

 -cvs S1 and S2 heard

 - RESPIRATORY SYSTEM dyspnea present

 -P/A- soft,non tender
  -CNS- NAD 


 Diagnosis: 

  CKD 2° ? NSAIDS , 

- DM since 12 yrs ,HTN since 3 yrs 
- Complains currently- (4/1/22) Chills and fever post   hemodialysis since the past 1 month 1 Session HD done yesterday

-  Soap notes 5/1/22
  
  S
  C/O chills 

  O
   Temp- afebrile 
   BP- 150/90 mmHg  
   PR- 91 BPM 
   CVS - S1S2 heard 
   RS- BAE +
   CNS - NAD
   P/A - soft,NT

  A
   CKD 2° ?NSAID abuse 
   HTN since 3 yrs 
   DM since 12 yrs 

  P
   Tab Nicardia 10 MG PO/OD 
   Tab Nodosis 500 MG PO/BD 
   Tab Arkamine 0.1 mg PO/TID 
   Tab Orofer xt PO/OD 
   Tab SHELCAL PO/OD
   Tab Pantop PO/OD 
   Tab Dolo 650 mg PO/ TID 
   Hemogram Hb- 5.9 mg /dl 
   TLC-11000 
    RFT Ur -79 
    Cr-6.5 UA-7.5 
    CUE - Alb- 1+ Sugar
  
 - trace SOAP NOTES 6/1/22

 S
 C/O tightness of abdomen since 5 days

   O
  Temp- afebrile 
  BP- 150/90 mmHg
  PR- 91 BPM 
  CVS - S1S2 heard 
  RS- BAE + 
  CNS - NAD P/A - soft,NT 

 A 
  CKD 2° ? NSAID ?
  DM SINCE 12 YEARS 
   HTN SINCE 3 YEARS 

 P
   Tab Nicardia 10 MG PO/OD
   Tab Nodosis 500 MG PO/BD
   Tab Arkamine 0.1 mg PO/TID
   Tab Orofer xt PO/OD 
   Tab SHELCAL PO/OD 
   Tab Pantop PO/OD 
   Tab Dolo 650 mg PO/ TID 


 SOAP NOTES (8/1/22) 

 S 
 C/O tightness of abdomen 1 episode of fever spike @4 am 

 O 
  Temp- afebrile 
  BP- 140/100 mmHg 
  PR- 90 BPM
  CVS - S1S2 heard 
   RS- BAE + 
   CNS - NAD 

 A 
 CKD 2° ? NSAID ?
 DM SINCE 12 YEARS
 HTN SINCE 3 YEARS

 P
 Tab Nicardia 10 MG PO/OD 
 Tab Nodosis 500 MG PO/BD  
 Tab Arkamine 0.1 mg PO/TID 
 Tab Orofer xt PO/OD 
 Tab SHELCAL PO/OD 
 Tab Pantop PO/OD 
 Tab Dolo 650 mg PO/ TID 
 Tab kinpride 1mg PO/BD 
 Tab Rantac 150 mg PO/ BD 



 Reports : 24/12/21
8/1/22 USG abdomen
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