CKD case of 60 year old male 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-centered online learning portfolio and your valuable inputs on the comment box"

 60 year old male, farmer by occupation,  came to Medicine OPD with complaints of : 


Chief complaints

Facial puffiness from 10 days, shortness of breath from 10 days and bilateral pedal deems from 10 days


History of present illness

Patient was apparently asymptomatic 6 months back, then he developed pain in lower back  for which he took NSAIDS daily and was not having any complaints , but from last 10 days he developed facial puffiness ,shortness of breath and bilateral pedal oedema 
associated burning Micturition and abdominal distension 


Past history

History of hypertension and was on regular medication (unknown)from 1 month
No history of fever
No history of Nausea and vomiting
No history of Diabetes 
No history of tuberculosis 
No history of epilepsy
No history of asthma 

Personal history 


Diet - mixed
Appetite is normal
Bowel and bladder - normal and regular
 No Known allergies
  Addictions - regular alcohol consumption approx 90 ml

Family history


His family members are not having any relevant issues 

General examination


Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished


Icterus is absent 

Pedal edema - present (pitting type)     

Pallor is present 

No cyanosis, clubbing , lymphadenopathy .




















Vitals : 

Temperature- afebrile

Respiratory rate - 28 cpm

Pulse rate - 92 bpm 

BP - 160/100 mm Hg.

Spo2 at room air is 98%

GRBS - 126 mg/dl

SYSTEMIC EXAMINATION: 


CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard(vesicular)


Abdominal examination: 

INSPECTION : 

      Shape of abdomen- scaphoid

-No tenderness of abdomen 

  • Umblicus - normal
  • Movements of abdominal wall - moves with respiration 
  • Skin is smooth and shiny


PALPATION : 

No Local rise of temperature

Tenderness absent

Guarding present

Rigidity absent 

hernial orifices normal

Fluid thrill absent

Liver not palpable .

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 


CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++


Gait: normal


Investigations


Serology: 

HIV - negative 

HCV - negative 

HBsAg - negative 




















Provisional diagnosis

Chronic kidney disease secondary to NSAIDS?

TREATMENT 


P: T. NICARDIA 10 MG PO BD
     T. NODOSIS 500 MG PO BD
     T. OROFER XT PO BD
      T. SHELCAL PO BD
    INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE

SOAP NOTES : 28/11/22
S:
   SOB subsided 
   Bilateral pitting oedema
O: vitals
     Temperature- afebrile

Pulse rate- 96 b/m

Respiratory rate- 20 cpm

Bp- 150/100 mmhg


A: chronic renal failure secondary to NSAIDS

P: T. NICARDIA 10 MG PO BD
     T. NODOSIS 500 MG PO BD
     T. OROFER XT PO BD
      T. SHELCAL PO BD
    INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE

SOAP NOTES : 29/11/22
S:
   SOB subsided 
   Bilateral pitting oedema
O: vitals
     Temperature- afebrile

Pulse rate- 98 b/m

Respiratory rate- 20 cpm

Bp- 150/100 mmhg


A: chronic renal failure secondary to NSAIDS

P: T. NICARDIA 10 MG PO BD
     T. NODOSIS 500 MG PO BD
     T. OROFER XT PO BD
      T. SHELCAL PO BD
       T. SPOROLACT BD
    INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE

SOAP NOTES : 30/11/22
S:
   SOB subsided 
   Bilateral pitting oedema
O: vitals
     Temperature- afebrile

Pulse rate- 96 b/m

Respiratory rate- 20 cpm

Bp- 160/100 mmhg

GRBS- 128mg%

A: chronic renal failure secondary to NSAIDS

P: T. NICARDIA 10 MG PO BD
     T. NODOSIS 500 MG PO BD
     T. OROFER XT PO BD
      T. SHELCAL PO BD
    INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE







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