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65 year old male patient came to OPD with C/o of shortness of breath grade 2 to grade 3 according to a NYHA classification since 15 days
C/o bilateral pedal edema(on and off since 2 yrs) and complain of decreased urine output since 2 months
C/o decreased appetite
C/o bilateral pedal edema(on and off since 2 yrs) and complain of decreased urine output since 2 months
C/o decreased appetite
A 65 year old male who is farmer by occupation was apparently asymptomatic 14 years back doing all his routine activities and then he met with an RTA and sustain low back ache for which he was conservatively treated for six days and then discharged which is followed by recurrent back ache for which he took NSAIDS for 10 years in nearby hospital followed by herbal medication .
Two years back he noticed bilateral pedal edema and went to local hospital and treated conservatively and then pedal edema is on and off. 2 months back he noticed decreased urine output
Since 15 days he complain of shortness of breath grade 2 to grade 3
Since 15 days he complain of shortness of breath grade 2 to grade 3
Since 15 days he complain of shortness of breath grade 2 to grade 3
Since 15 days he complain of shortness of breath grade 2 to grade 3
Not a k/c/o DM/ asthma/ epilepsy/ Thyroid/ CAD /TB
No H/O surgeries, blood transfusions
Personal history :
marital status: married
Diet - mixed
Appetite - decreased
Sleep - adequate
Bowel movements : regular
Bladder movements : decreased urine output
occasionally drinks alcohol and has habit of smoking
marital status: married
Diet - mixed
Appetite - decreased
Sleep - adequate
Bowel movements : regular
Bladder movements : decreased urine output
occasionally drinks alcohol and has habit of smoking
Family history:
no k/c/o DM/ HTN/ TB/ Asthma/ Heart disease/ cancer/ stroke
no k/c/o DM/ HTN/ TB/ Asthma/ Heart disease/ cancer/ stroke
General examination:
pallor +
no cyanosis, lymphadenopathy, icterus, clubbing, dehydration
Temp- 97.7 F
PR- 112/ min
RR-20/min
BP-150/80mm of Hg
GRBS: 184 mg%
SPO2- 97% at room air
pallor +
no cyanosis, lymphadenopathy, icterus, clubbing, dehydration
Temp- 97.7 F
PR- 112/ min
RR-20/min
BP-150/80mm of Hg
GRBS: 184 mg%
SPO2- 97% at room air
CVS: S1,S2 heard no thrills and murmurs
RS: BAE +,NVBS
no dyspnoea, wheeze
P/A: soft , Non tender
scaphoid shape, no tenderness, no palpable mass, no free fluid
Bowel sounds heard
no dyspnoea, wheeze
P/A: soft , Non tender
scaphoid shape, no tenderness, no palpable mass, no free fluid
Bowel sounds heard
CNS : pt is conscious, coherent, cooperative, NAD.
K/c/o Hypertension since 1month ( on tab atenolol 10mg, irregular medication)
Provisional diagnosis: NSAIDS INDUCED NEPHROPATHY WITH CKD WITH METABOLIC ACIDOSIS WITH HTN (1MONTH)
Treatment:
Fluid restriction (<1l/day)
Salt restriction (<2g/day)
INJ· LASIX 40 mg IV/ TID.
T. NODOSIS 500 MG PO BD
T. OROFER-XR PO OD
T. SHELCAL-CT PO OD
STRICT I/O MONITORING.
Lumbo sacral x ray Ap &Lateral view taken on 01-02-21.
C/o pain in bilateral lower limbs.
C/0 backache
C/0 fever
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 7ibpm
Temp:febrile
Last dialysis was done on 10/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,SALT RESTRICTION 2G/DAY.
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/BD
4.INJ.LASIX 40 MG/IV/BD
5.TAB.NODOSIS 550 MG/PO/BD
6.TAB.SHELCAL 50P MG/PO
7.TAB PCM 650MG/PO/BD.
8.TAB CEFIXIME 200MG/PO/QID.
9.TAB ULTRACET PO/QID
10.INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F
11.MONITOR VITALS AND URINE I/O.
C/o pain in MULTIPLE JOINTS IN BOTH LIMBS BILATERALLY
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 80 bpm
Temp: febrile
Last dialysis was done on 13/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ? NSAID abuse ? NSAID induced nephropathy, K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,SALT RESTRICTION 2G/DAY.
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/BD
4.INJ.LASIX 40 MG/IV/BD
5.TAB.NODOSIS 550 MG/PO/BD
6.TAB.SHELCAL 50P MG/PO
7.TAB PCM 650MG/PO/BD.
8.TAB CEFIXIME 200MG/PO/QID.
9.TAB ULTRACET PO/QID
10.INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F
15/12/21
S:
C/o pain in bilateral lower limbs.
C/0 backache
C/0 fever
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 75bpm
Temp:febrile
Last dialysis was done on 10/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,SALT RESTRICTION 2G/DAY.
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/BD
4.INJ.LASIX 40 MG/IV/BD
5.TAB.NODOSIS 550 MG/PO/BD
6.TAB.SHELCAL 50P MG/PO
7.TAB PCM 650MG/PO/BD.
8.TAB CEFIXIME 200MG/PO/QID.
9.TAB ULTRACET PO/QID
10.INJ.NEOMAL 1 GM/IV IF TEMP >101.1 F
S:
C/o pain in bilateral lower limbs.
C/0 backache
C/0 fever
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 78bpm
Temp:febrile
Last dialysis was done on 10/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,with rheumatoid arthritis, K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,
SALT RESTRICTION 2G/DAY.
2. TAB.NODOSIS 550 MG/PO/BD
3.TAB.SHELCAL 50P MG/PO
4. TAB PCM 650MG/PO/BD.
5. TAB ULTRACET PO/QID
6.Tab Methotrexate 7.5mg weekly once
7. Tab Folic acid 5mg on every alternative day
8. INJ.NEOMAL 1 GM/IV IF TEMP >101.1 F
Soap notes
17/12/21
Treatment:
Fluid restriction (<1l/day)
Salt restriction (<2g/day)
INJ· LASIX 40 mg IV/ TID.
T. NODOSIS 500 MG PO BD
T. OROFER-XR PO OD
T. SHELCAL-CT PO OD
STRICT I/O MONITORING.
Lumbo sacral x ray Ap &Lateral view taken on 01-02-21.
S:
C/o pain in bilateral lower limbs.
C/0 backache
C/0 fever
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 7ibpm
Temp:febrile
Last dialysis was done on 10/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,SALT RESTRICTION 2G/DAY.
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/BD
4.INJ.LASIX 40 MG/IV/BD
5.TAB.NODOSIS 550 MG/PO/BD
6.TAB.SHELCAL 50P MG/PO
7.TAB PCM 650MG/PO/BD.
8.TAB CEFIXIME 200MG/PO/QID.
9.TAB ULTRACET PO/QID
10.INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F
11.MONITOR VITALS AND URINE I/O.
Soap notes 14/12/21
S:
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 80 bpm
Temp: febrile
Last dialysis was done on 13/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ? NSAID abuse ? NSAID induced nephropathy, K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,SALT RESTRICTION 2G/DAY.
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/BD
4.INJ.LASIX 40 MG/IV/BD
5.TAB.NODOSIS 550 MG/PO/BD
6.TAB.SHELCAL 50P MG/PO
7.TAB PCM 650MG/PO/BD.
8.TAB CEFIXIME 200MG/PO/QID.
9.TAB ULTRACET PO/QID
10.INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F
11.MONITOR VITALS AND URINE I/O.
S:
C/o pain in bilateral lower limbs.
C/0 backache
C/0 fever
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 75bpm
Temp:febrile
Last dialysis was done on 10/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,SALT RESTRICTION 2G/DAY.
2.INJ.PANTOP 40 MG/IV/OD
3.INJ.ZOFER 4 MG/IV/BD
4.INJ.LASIX 40 MG/IV/BD
5.TAB.NODOSIS 550 MG/PO/BD
6.TAB.SHELCAL 50P MG/PO
7.TAB PCM 650MG/PO/BD.
8.TAB CEFIXIME 200MG/PO/QID.
9.TAB ULTRACET PO/QID
10.INJ.NEOMAL 1 GM/IV IF TEMP >101.1 F
11.MONITOR VITALS AND URINE I/O.
Soap notes
16/12/21S:
C/o pain in bilateral lower limbs.
C/0 backache
C/0 fever
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 78bpm
Temp:febrile
Last dialysis was done on 10/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,with rheumatoid arthritis, K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,
SALT RESTRICTION 2G/DAY.
2. TAB.NODOSIS 550 MG/PO/BD
3.TAB.SHELCAL 50P MG/PO
4. TAB PCM 650MG/PO/BD.
5. TAB ULTRACET PO/QID
6.Tab Methotrexate 7.5mg weekly once
7. Tab Folic acid 5mg on every alternative day
8. INJ.NEOMAL 1 GM/IV IF TEMP >101.1 F
9. MONITOR VITALS AND URINE I/O.
17/12/21
S:
C/o pain in bilateral lower limbs.
C/0 chest pain
C/0 reduced appetite
Didn't pass stools since 3 days
C/o pain in bilateral lower limbs.
C/0 chest pain
C/0 reduced appetite
Didn't pass stools since 3 days
O:
Pt is c/c/c
Bp:140/90mmhg
PR: 78bpm
Temp:febrile
Last dialysis was done on 10/12/21.
K/c/o HTN since 1month.
Pt is c/c/c
Bp:140/90mmhg
PR: 78bpm
Temp:febrile
Last dialysis was done on 10/12/21.
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,with rheumatoid arthritis, K/c/o HTN since 1 month.
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,with rheumatoid arthritis, K/c/o HTN since 1 month.
P:
4th session of dialysis done yesterday
1.FLUID RESTRICTION 2L/DAY,
SALT RESTRICTION 2G/DAY.
2. TAB.NODOSIS 550 MG/PO/BD
3..TAB.SHELCAL 50P MG/PO
4. TAB PCM 650MG/PO/BD.
5. TAB ULTRACET PO/QID
6.Tab Methotrexate 7.5mg weekly once
7. Tab Folic acid 5mg on every alternative day
8. INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F
9. Inj. Erythropoietin 4000 IU - WEEKLY ONCE
10. Syp. Lactulose 10 ml po/h/s
11. MONITOR VITALS AND URINE I/O.
4th session of dialysis done yesterday
1.FLUID RESTRICTION 2L/DAY,
SALT RESTRICTION 2G/DAY.
2. TAB.NODOSIS 550 MG/PO/BD
3..TAB.SHELCAL 50P MG/PO
4. TAB PCM 650MG/PO/BD.
5. TAB ULTRACET PO/QID
6.Tab Methotrexate 7.5mg weekly once
7. Tab Folic acid 5mg on every alternative day
8. INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F
9. Inj. Erythropoietin 4000 IU - WEEKLY ONCE
10. Syp. Lactulose 10 ml po/h/s
11. MONITOR VITALS AND URINE I/O.
Soap notes
22/12/21
S:
C/o pain in bilateral lower limbs.,
C/0 neck pain
C/0 reduced appetite
Fever spikes +
B/L Pedal edema +
22/12/21
S:
C/o pain in bilateral lower limbs.,
C/0 neck pain
C/0 reduced appetite
Fever spikes +
B/L Pedal edema +
O:
Pt is c/c/c
Bp:160/70mmhg
PR: 78bpm
Temp: 99F
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,with rheumatoid arthritis, K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,
SALT RESTRICTION 2G/DAY.
2. TAB.NODOSIS 550 MG/PO/BD
3..TAB.SHELCAL 50P MG/PO
4. TAB PCM 650MG/PO/BD.
5. TAB ULTRACET PO/QID
6.Tab Methotrexate 7.5mg weekly once
7. Tab Folic acid 5mg on every alternative day
8. INJ.NEOMAL 1 GM/IV IF TEMP >101.1F
9. Inj. Erythropoietin 4000 IU - WEEKLY ONCE
Pt is c/c/c
Bp:160/70mmhg
PR: 78bpm
Temp: 99F
K/c/o HTN since 1month.
A:
CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,with rheumatoid arthritis, K/c/o HTN since 1 month.
P:
1.FLUID RESTRICTION 2L/DAY,
SALT RESTRICTION 2G/DAY.
2. TAB.NODOSIS 550 MG/PO/BD
3..TAB.SHELCAL 50P MG/PO
4. TAB PCM 650MG/PO/BD.
5. TAB ULTRACET PO/QID
6.Tab Methotrexate 7.5mg weekly once
7. Tab Folic acid 5mg on every alternative day
8. INJ.NEOMAL 1 GM/IV IF TEMP >101.1F
9. Inj. Erythropoietin 4000 IU - WEEKLY ONCE
10. MONITOR VITALS AND URINE I/O.
Any reviews ,comments, inputs, advices about the content presented is absolutely welcome !!!
Thanks & Regards,
Nomika Alli
3rd SEM
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