48 yr old patient
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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
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