48 Year old Male with bipedal edema RACHANA GANGULA INTERN

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 



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  

 


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 


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  

 


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 


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  
 

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 

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 


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  
 

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 

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  
 

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  
 

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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