60 year male with sob and b/l pedal edema
60yr old patient with ckd
November 30,2022
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
-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-cen
tred online learning portfolio and your valuable comments on comment box is welcome.
Nitin Raj
03
CHIEF COMPLAINTS: C/O facial puffiness,c/o sob,c/o b/l pedal oedema since 10 days
HISTORY OF PRESENTING ILLNESS
- Patient was apparently asymptomatic 6 months ago later he developed back pain for which he took NSAIDS once in 2-3 days which was releived,later from last 10 days he developed facial puffiness,sob grade 2 and bilateral pedal oedema(pitting type) associated burning Micturition and abdominal distension
There Is no h/o of fever nausea vomiting diarrhea
HISTORY OF PAST ILLNESS
K/c/o HTN: 1month (on regular medication unknown)
N/k/c/o : DM,TB,EPILEPSY,CAD.
TREATMENT HISTORY:
He is on NSAID medication for lower back ache .
PERSONAL HISTORY:
DIET : Vegetarian
Appetite normal
Micturition normal
Bowel and bladder movements regular
ON EXAMINATION
Patient is conscious ,coherent and cooperative
well oriented to time,place and person
pallor
No icterus
No cyanosis
No lympahdenopathy
Pitting type of oedema(bilateral)
On the time of admission:
Temperature- 98.2 c/f
Pulse rate- 92 b/m
Respiratory rate- 20 cpm
Bp- 160/100 mmhg
GRBS- 126mg/dl
ON SYSTEMIC EXAMINATION
CVS-S1,S2 heard
No murmurs
RS- BAE +
ABDOMEN- inspection- scaphoid shape
No tenderness,skin is smooth and shiny,no scars,sinuses
Palpation- no local rise of Temperature,tenderness absent,guarding present,hernial orifice normal,fluid thrill absent,liver not palatable,seen not palpable
CNS- conscious,speech normal,no signs of meningeal irritation,sensory and motor system normal,gait- normal.
DIAGNOSIS- CHRONIC KIDNEY DISEASE SECONDARY TO NSAIDS ?
Investigations
SOAP NOTES : 22/11/22
S:facial puffiness since 10 days
SOB Bilateral pitting oedema
O: vitals
Temperature- 98.2 c/f
Pulse rate- 92 b/m
Respiratory rate- 20 cpm
Bp- 160/100 mmhg
GRBS- 126mg%
A: chronic renal failure secondary to NSAIDS
P: T. NICARDIA 20 MG PO BD
T. NODOSIS 500 MG PO BD
T. MET XL 25 MG PO BD
T. OROFER XT PO BD
T. SHELCAL PO BD
INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE AFTER DIALYSISTemperature- 98.2 c/f
Pulse rate- 92 b/m
Respiratory rate- 20 cpm
Bp- 160/100 mmhg
GRBS- 126mg%
A: chronic renal failure secondary to NSAIDS
P: T. NICARDIA 20 MG PO BD
T. NODOSIS 500 MG PO BD
T. MET XL 25 MG PO BD
T. OROFER XT PO BD
T. SHELCAL PO BD
T. LASIX 40 MG PO OD
High risk central line consent was taken
DIALYSIS
ON 23/11/22
PRE DIALYSIS
VITALS:BP: 180/80 MMHG
PR: 79 BPM
SPO2: 99%
RFT:
UREA-195
CREATININE: 17.2
URIC ACID: 7.7
HB: 6.5
DURING DIALYSIS:
BP: 180/60
PR: 89
SPO2: 99%
POST DIALYSIS:
BP: 160/70
ON 24/11/22
RFT:
UREA:114
CREATININE:10.0
URIC ACID:4.7
HB:9.1
SOAP NOTES : 23/11/22
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
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 T. SHELCAL PO BD
BLOOD TRANSFUSION DONE (PRBC)
SOAP NOTES : 24/11/22
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
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 ONCET. SHELCAL PO BD
SOAP NOTES : 25/11/22
S:
SOB subsided
Bilateral pitting oedema
O: vitals
Temperature- afebrile
Pulse rate- 84 b/m
Respiratory rate- 20 cpm
Bp- 140/90 mmhg
A: chronic renal failure secondary to NSAIDS
P: T. NICARDIA 10 MG PO BD
T. NODOSIS 500 MG PO BD
Bilateral pitting oedema
O: vitals
Temperature- afebrile
Pulse rate- 84 b/m
Respiratory rate- 20 cpm
Bp- 140/90 mmhg
A: chronic renal failure secondary to NSAIDS
P: T. NICARDIA 10 MG PO BD
T. NODOSIS 500 MG PO BD
T. MET XL 25MG PO OD
T. OROFER XT PO BD
T. SHELCAL PO BD
INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCET. SHELCAL PO BD
SOAP NOTES : 26/11/22
S:
SOB subsided
Bilateral pitting oedema
O: vitals
Temperature- afebrile
Pulse rate- 97 b/m
Respiratory rate- 20 cpm
Bp- 150/100 mmhg
GRBS- 128mg%
A: chronic renal failure secondary to NSAIDS
P: T. NICARDIA 10 MG PO BD
T. NODOSIS 500 MG PO BD
Bilateral pitting oedema
O: vitals
Temperature- afebrile
Pulse rate- 97 b/m
Respiratory rate- 20 cpm
Bp- 150/100 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 ONCET. SHELCAL PO BD
SOAP NOTES : 27/11/22
S:
SOB subsided
Bilateral pitting oedema
O: vitals
Temperature- afebrile
Pulse rate- 98 b/m
Respiratory rate- 20 cpm
Bp- 140/100 mmhg
A: chronic renal failure secondary to NSAIDS
P: T. NICARDIA 10 MG PO BD
T. NODOSIS 500 MG PO BD
Bilateral pitting oedema
O: vitals
Temperature- afebrile
Pulse rate- 98 b/m
Respiratory rate- 20 cpm
Bp- 140/100 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 ONCET. SHELCAL PO BD
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
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 ONCET. SHELCAL PO BD
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
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. SHELCAL PO BD
T. SPOROLACT BD
INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCESOAP 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
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 ONCET. SHELCAL PO BD
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