CKD case
General Medicine E-log
A 45 year old male came to the OPD with complaints of shortness of breath, pedal edema and abdominal distention.
Chief complaints:
The patient came to the OPD in august with complaints of shortness of breath (grade IV), pedal edema and abdominal distention.
He has been feeling diffuse pain of non radiating type in the chest region since the past 3 days. It was not associated with palpitations or sweating.
History of present illness:
The patient was asymptomatic 3 months ago when he developed shortness of breath, pedal edema and abdominal distention.
He was a known case of CKD since the past 2 years.
After he had contracted COVID-19 4 months ago, the symptoms of CKD were exacerbated and dialysis was started after he was admitted in the hospital on 27/09/2021.
Patient had no C/O fever, vomiting, loose stools, pain abdomen, orthopnea and PND.
History of past illnesses:
The patient was a known case of hypertension since 6 years and has been on medication for the same since the past 3 years. He stopped using the medication for the 8 months preceding the onset of symptoms. After which, he started using them again.
He has also been suffering from chronic kidney disease (CKD) since the past 2 years for which he was on medication.
He also recently contracted COVID-19 4 months ago (infection lasted for 12 days).
He is not a known case of DM, asthma, epilepsy and thyroid disorders.
Personal history:
Occupation:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder habits: regular
Micturition: normal
Addictions: he regularly consumes alcohol (around 3 times a week), about 90-250 ml. He stopped alcohol consumption 4 months ago.
No known drug allergies.
Family history:
No significant family history.
General examination:
Patient is moderately built and moderately nourished.
He is conscious, coherent and co-operative.
Pedal edema (pitting type) is seen.
There is no pallor, icterus, cyanosis, clubbing, lyphadenopathy or dehydration.
Vitals:
Temperature: 98.4°F
PR: 84/min
RR: 24/min
BP: 140/100 mmHg
SPO2 at room air: 98%
GRBS: 126 mg/dl
Systemic examination:
CNS:
Patient is conscious
Speech: normal
No signs of meningeal irritation
Motor and sensory systems: normal
Cranial nerves: intact
CVS:
S1, S2 were heard
No murmurs
No thrills
Respiratory system:
Position of Trachea: central
BAE: present
NVBS heard
No added sounds
Per Abdomen:
Soft, non tender
Hernial orifices are normal
No palpable masses
Bowel sounds heard
Position of Trachea: central
BAE: present
NVBS heard
No added sounds
Per Abdomen:
Soft, non tender
Hernial orifices are normal
No palpable masses
Bowel sounds heard
Provisional diagnosis:
CKD on MHD
(Dialysis starter on 02/08/2021)
Investigations:
On 24/09/2021
On 13/10/2021
On 14/10/2021
Ultrasound report
ECG
Final diagnosis:
CKD on MHD
Known case of HTN (since 6 years).
Treatment given (present course in the hospital):
27/09/2021
Rx
Fluid restriction <1.5L/day
Salt restriction <2mg/day
Tab. LASIX 40mg PO/BD
Tab. NICARDIA 20mg PO/TID
Tab. CLONIDINE 0.1mg PO/TID
Tab. MET-XL 50mg PO/OD
Tab. LIVOGEN PO/BD
Tab. BIO-D3 0.25mg PO/BD
Tab. SHELCAL CT 500mg PO/BD
Inj. ERYTHROPOIETIN 4000 IU S/C weekly once.
28/09/2021
Rx
Tab. LASIX 40mg PO/BD
Tab. NICARDIA 20mg PO/TID
Tab. CLONIDINE 0.1mg PO/TID
Tab. MET-XL 50mg PO/OD
Tab. LIVOGEN PO/BD
Tab. BIO-D3 0.25mg PO/BD
Tab. SHELCAL CT 500mg PO/BD
29/09/2021
Rx
Fluid restriction <1.5L/day
Salt restriction <2mg/day
Tab. LASIX 40mg PO/BD
Tab. NICARDIA 20mg PO/TID
Tab. CLONIDINE 0.1mg PO/TID
Tab. MET-XL 50mg PO/OD
Tab. LIVOGEN PO/BD
Tab. BIO-D3 0.25mg PO/BD
Tab. SHELCAL CT 500mg PO/BD
Inj. ERYTHROPOIETIN 4000 IU S/C weekly once.
30/09/2021
Rx
Tab. LASIX 40mg PO/BD
Tab. NICARDIA 20mg PO/TID
Tab. CLONIDINE 0.1mg PO/TID
Tab. MET-XL 50mg PO/OD
Tab. LIVOGEN PO/BD
Tab. BIO-D3 0.25mg PO/BD
Tab. SHELCAL CT 500mg PO/BD
Inj. ERYTHROPOIETIN 4000 IU
5/10/2021
Rx
Inj. ERYTHROPOIETIN 4000 IU weekly twice.
10/102021
Rx
Inj. ERYTHROPOIETIN 4000 IU weekly twice.
13/10/2021
Rx
Fluid restriction <1.5L/day
Salt restriction <2mg/day
Tab. LASIX 40mg PO/BD
Tab. NICARDIA 20mg PO/TID
Tab. CLONIDINE 0.1mg PO/TID
Tab. MET-XL 50mg PO/OD
Tab. LIVOGEN PO/BD
Tab. BIO-D3 0.25mg PO/BD
Tab. SHELCAL CT 500mg PO/BD
Inj. ERYTHROPOIETIN 4000 IU S/C weekly once.
14/10/2021
Rx
Fluid restriction <1.5L/day
Salt restriction <2mg/day
Tab. LASIX 40mg PO/BD
Tab. NICARDIA 20mg PO/TID
Tab. CLONIDINE 0.1mg PO/TID
Tab. MET-XL 50mg PO/OD
Tab. LIVOGEN PO/BD
Tab. BIO-D3 0.25mg PO/BD
Tab. SHELCAL CT 500mg PO/BD
Inj. ERYTHROPOIETIN 4000 IU S/C weekly once.
18/10/2021
Rx
Fluid restriction <1.5L/day
Salt restriction <2mg/day
Tab. LASIX 40mg PO/BD
Tab. NICARDIA 20mg PO/TID
Tab. CLONIDINE 0.1mg PO/TID
Tab. MET-XL 50mg PO/OD
Tab. LIVOGEN PO/BD
Tab. BIO-D3 0.25mg PO/BD
Tab. SHELCAL CT 500mg PO/BD
Inj. ERYTHROPOIETIN 4000 IU S/C weekly once.
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