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55 YR OLD MALE WITH CKD ON MHDPt came with complaints of Pedal edema & SOB since 3 months


55 YR OLD MALE WITH CKD ON MHD

Pt came with complaints of 
           -     Pedal edema
           -     SOB   since   3 months
Patient  was apparently asymptomatic  8 months back  , then he  developed  knee & ankle pain  in both lower limbs , then he went to local hospital and took medication for that pain relief.
He used that medication 4-5 months ,after  he developed pedal edema which was pitting type &
SOB , which was grade 2-3 since 3 months


Past history : k/C/O HTN since 3 months
               Not a known case of DM  ,asthma,TB , EPILEPSY
Personal history :
      Diet - mixed
      Appetite - normal
     B&B movements - regular
     
Family history : not significant
  ON EXAMINATION :
Pt is C/C/C
Temp : afebrile
BP : 140/80 mmHg
PR : 82 BPM
Rs :22 CPM
GRBS : 105 mg%
General examination
Pallor + , no icterus , Cyanosis , Clubbing ,   lymphadenopathy
B/L Pedal edema +



On systemic examination :
CVS : S1S2 +
RS : BAE +
Per abdomen : soft non tender
CNS : NAD

Investigations :


ECG
           

2D ECHO

Chest x-ray




          



provisional diagnosis : CKD on MHD Secondary to NSAIDS Induced nephropathy

Treatment : 

1) salt restriction <2.4 GM/day
2) fluid restriction  < 1 lit / day
3) Tab lasix 40 mg Po/TID
4) Tab .NODOSIS  550 mg po/ BAD
5) Tab OROFER XT po/ of
6) Tab SHELCAL 500 mg  po/ of
7) inj Erythropoietin 4000 IU / SC weekly once
8) inj iron sucrose 1 amp in 100 ml NS
9) strict i/o charting

Ckd ward

NEPHROLOGY

SOAP NOTES
DAY 2
S :

Abdominal tightness since mrng
SOB decreased

No fresh complaints.

O :

O/E
Pt is c/c/c

Temp 98.4 F
BP 140/80 mm hg
PR 86
RR 20
GRBS  99 mg/dl

CVS: S1S2+
No murmurs

RS:
BAE +
Trachea position-central.
Vesicular breath sounds heard

P/A:
    Soft, non tender
       DISTENDED
          Bowel sounds heard .
CNS: NAD

Provisional diagnosis : CKD on MHD Secondary to NSAIDS Induced nephropathy



Treatment :

) salt restriction <2.4 GM/day
2) fluid restriction  < 1 lit / day
3) Tab lasix 40 mg Po/TID
4) Tab .NODOSIS  550 mg po/ BAD
5) Tab OROFER XT po/ of
6) Tab SHELCAL 500 mg  po/ of
7) inj Erythropoietin 4000 IU / SC weekly once
8) inj iron sucrose 1 amp in 100 ml NS
9) strict i/o charting

COMMENTS

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