A 48 year old man with chronic kidney disease

Student Name- D.Vineesha Chowdary 

2017 Batch

Roll no.- 24

This is 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 patients 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 comment box is welcome.

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan. 


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

 
With 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 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 1

8/1/22 
USG abdomen 


 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

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

 

Reports : 24/12/21













8/1/22 
USG abdomen 



 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

 

Reports : 24/12/21













8/1/22 
USG abdomen 



Comments

Post a Comment

Popular posts from this blog

General medicine monthly assignment

  SECTION 1: (PULMONOLOGY) 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? Ans: The patient's symptoms started 20 years ago during the winter season, and recurred very year during the same time. This indicates a gradual progression of shortness of breath. The seasonal incidence indicates the seasonal exacerbation of COPD. The anatomical localisation of the problem is in the lungs, specifically bronchial tubes. The ethology of this may be due to environmental exposure to pollutants. 2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient? Ans: Head end elevation improves the breathing due to orthostatic dyspnoea as associated with the heart failure here. The O2 inhalation is shown to increase the O2 saturation and mai...
Read more

67 year old patient with acute coronary syndrome

Image
 May 14,2021 Student Name- D.Vineesha Chowdary  2017 batch This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.  HISTORY OF PRESENTING ILLNESS: A 67 year old female patient came to the OPD with C/O shortness of breath (SOB) since 1/2 hour. She had H/O heartburn like ...
Read more

80 year old female with complaints of shortness of breath and chest pain

Image
 Student Name- D.Vineesha Chowdary  2017 batch This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.  A 80 year old female came to casualty with complaints of shortness of breath and chest pain since 2pm on (25/3/22) HISTORY OF PRESENTING ILLNESS: Patient was apparent...
Read more