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.
48 year old man resident of Nalgonda and farmer by occupation came to the hospital with chief complaints of bilateral pedal oedema and sudden onset dyspnea around 3 months back and has been visiting the hospital for regular dialysis ever since then.
HOPI-
Patient was apparently asymptotic 20 yrs back when he developed lower back pain for which he visited the hospital and was diagnosed with renal calculi and diabetes, for which he used medication for 3 years and underwent surgery for renal calculi later.His lower back pain still hadn't subsided, so he visited a local RMP and used NSAIDS for 10-15 years.
3 years back, he developed bilateral pedal edema with shortness of breath following which he visited the hospital and was diagnosed with CKD and HTN after which he was put on conservative treatment for the same
He was on regular medication with regular followup, but due covid 19 lockdown he didn't had regular checkups for the past one year.
3 months back, he visited to hospital with bipedal edema and shortness of breath. The patient recalls that during this time his creatinine levels were 11 mg/ dl and was then he was started regular dialysis. He had 2 sessions of dialysis every week since then.
PAST HISTORY
Known case of diabetes since 20 years
Known case of hypertension since 3 years and on medication for the same.
FAMILY HISTORY
No significant family history
No history of CKD, DM,HTN,CVA, TB, Asthma or CAD among his immediate family members.
PERSONAL HISTORY
Diet: Mixed
Appetite: decreased recently
Sleep:Adequate
Bowel and bladder: Decreased urine output
No known drug allergies
No addictions
GENERAL EXAMINATION
Patient is conscious, coherant and cooperative, well oriented to time, place and person.
pallor- conjunctival pallor present
icterus, cyanosis, clubbing, lymphadenopathy- absent
Pedal edema- present, pitting edema
Vitals at the time of admission:
Temp-98.5
PR-92bpm
RR-26cpm
BP-130/70 mmHg
Spo2-93@ RA
CVS- S1S2 heard
RS- dyspnea present
P/A- soft,non tender
CNS- NAD
PROVISIONAL DIAGNOSIS
CKD 2° ? NSAIDS ,
DM since 20 years, 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 Day- 1
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 Day2
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
Lab reports
USG
CKD ward:
48 year old man
With DM type 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 sx 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 sob 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 at the time of admission:
Temp-98.5
PR-92bpm
RR-26cpm
BP-130/70 mmHg
Spo2-93@ RA
CVS- S1S2 heard
RS- 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
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 sx 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 sob 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 at the time of admission:
Temp-98.5
PR-92bpm
RR-26cpm
BP-130/70 mmHg
Spo2-93@ RA
CVS- S1S2 heard
RS- 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- afebrihis 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 sx 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 sob 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 at the time of admission:
Temp-98.5
PR-92bpm
RR-26cpm
BP-130/70 mmHg
Spo2-93@ RA
CVS- S1S2 heard
RS- 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
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 sx 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 sob 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 at the time of admission:
Temp-98.5
PR-92bpm
RR-26cpm
BP-130/70 mmHg
Spo2-93@ RA
CVS- S1S2 heard
RS- 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
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
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