A56 yr OLD MALE WITH CKD secondary to hypertensive nephropathy

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 evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 56 yr old male patient came with complaints of
-  Bilateral pedal edema since 20 days
C/o shortness of breath since 15 days

C/o decreased urine output  - since 15days

Pt was apparently asymptotic 3 months back then he developed  B/L pedal  edema (pitting type) , associated with shortness of breath grade 2-3 , then taken him to hospital pt diagnosed as CKD
He is on conservative management
Now, he came with same complaints since 20 days  now adviced for dialysis
Past history : k/C/O HTN since 2 yrs on irregular medication
Not a known case of DM, asthma , TB , Epilepsy
Personal history : farmer by occupation
Appetite : lost since 3 months
Diet : mixed
Bowel movements-regular

Bladder movement s irregular

No H/o addictions

Family history : not significant
On examination :

On general examination :

Vitals :
Pt is C/C/C
Temp -afebrile
BP -160/90 mmHg
PR -99 BPM
RR 18 CPMS -

Spo2 -95% at room air

GRBS-  115 mg%

Pallor +, no icterus , clubbing , cyanosis

Edema  +  ( B/L pedal edema)

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

investigations :  on 19/12/21

Hb - 8.1 GM/ dl

TC - 8,600

PlTC- 2.79 lakhs

RFT :

Urea :145 mg/ dl

Creatinine :14.4

Uric acid -6.7 mg/ dl

Calcium -7.1

Phosphorus -5.6

Sodium -149 meq/l

Potassium :5.6

Cl - 101 meq/l

CUE :

Albumin : +++

Sugars : nill

LFT :

TB :0.55 mg/ dl

DB : 0.2 mg/ dl

AST :17 IU/ l

ALT : 19 IU/ l

ALP :484 IU/l

TP :5.9 GM/ dl

Albumin :2.2 GM/ dl

A/G - 0.61

Serum  protein creatine ratio :4.34

21/12/21

Blood urea -167 mg/ dl

Sr creatinine :13

Uric acid :7.9

Electrolytes

Calcium -7.0 mg/ dl

Phosphorus - 6.3 mg/ dl

Na - 149 meq / l

K - 4.6 meq / l

Cl - 102 meq / l

22/12/21

Blood urea -176 mg/ dl

Uric acid -7.9 mg/ dl

Sr creatinine : 17.3 mg/ dl

Electrolyte s

Na -145 meq / l

K - 4.5 meq/l

Cl -101 meq/l

23/12/21

Hb - 8.2 GM/dl

Urea -126 mg/dl

Creatinine -12.9 mg/dl

Uric acid - 5.8 mg/dl

Ultrasound findings :

Provisional diagnosis : CRF with metabolic acidosis    k/C/O HTN since 10 months

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/ BD
5) Tab OROFER XT PO/ OD
6) Tab SHELCAL 500 mg  PO/ OD
7) inj Erythropoietin 4000 IU / SC weekly once
8) inj iron sucrose 1 amp in 100 ml NS
9) strict i/o charting

ECG

Chest X ray

1 session of hemodialysis was done with one PRBC  transfusion  on 22/12/21

2nd session was done at -24/12/21

3rd session was done at - 25/12/21

4th session was- 27/12/21

Soap notes :

23/12/21

56 yr old male 

CKD ward

S :

sob reduced

O : O/E

Pt is C/C/C

Temp - afebrile

BP -130/80 mmHg

PR - 82 BPM

CVS : S1S2 +

RS : BAE +

CNS : NAD

A : CKD  with secondary to  hypertensive nephropathy

P :

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 :

25/12/21

56 yr old male 

CKD ward

S :

sob reduced

O : O/E

Pt is C/C/C

Temp - afebrile

BP -130/90mmHg

PR - 82 BPM

CVS : S1S2 +

RS : BAE +

CNS : NAD

A : CKD  with secondary to  hypertensive nephropathy

P :

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/ Bd
5) Tab OROFER XT po/ od
6) Tab SHELCAL 500 mg  po/ od
7) inj Erythropoietin 4000 IU / SC weekly once
8) inj iron sucrose 1 amp in 100 ml NS
9) strict i/o charting

http://mounika107.blogspot.com/2021/12/a56-yr-old-male-with-crf.html

Soap notes :

27/12/21

56 yr old male 

CKD ward

S :

sob reduced

O : O/E

Pt is C/C/C

Temp - afebrile

BP -120/80mmHg

PR - 76 BPM

CVS : S1S2 +

RS : BAE +

CNS : NAD

A : CKD  with secondary to  hypertensive nephropathy

P :

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/ Bd
5) Tab OROFER XT po/ od
6) Tab SHELCAL 500 mg  po/ od
7) inj Erythropoietin 4000 IU / SC weekly once
8) inj iron sucrose 1 amp in 100 ml NS
9) strict i/o charting

http://mounika107.blogspot.com/2021/12/a56-yr-old-male-with-crf.html