CKD CASE

45 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 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

    Sleep -adequate  

     

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

CHEST X RAY

2D ECHO

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

Soap notes 

CKD CASE, 45/M

SUBJECTIVE-

Pedal edema reduced

No fever spikes

OBJECTIVE : 

patient is C/C/C

Temp : 98.3° F

BP- 140/80 mm Hg

PR- 100 bpm

Central Nervous System- NAD

Cardiovascular system- S1,S2 heard 

P/A - Tenderness 

Respiratory System- BAE +

ASSESSMENT 

CKD on MHD

PLAN OF CARE 

Dialysis

Tab.NICARDIA 10 mg

Tab.NODOSIS 550 mg 

Tab.SHELCAL 500 mg 

Tab.LASIX 40 mg