CKD case of 60 year old male patient 

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 60 year old male, farmer by occupation,  came to Medicine OPD with complaints of : 

Chief complaints

Facial puffiness from 10 days, shortness of breath from 10 days and bilateral pedal deems from 10 days

History of present illness

Patient was apparently asymptomatic 6 months back, then he developed pain in lower back  for which he took NSAIDS daily and was not having any complaints , but from last 10 days he developed facial puffiness ,shortness of breath and bilateral pedal oedema 

associated burning Micturition and abdominal distension 

Past history

History of hypertension and was on regular medication (unknown)from 1 month

No history of fever

No history of Nausea and vomiting

No history of Diabetes 

No history of tuberculosis 

No history of epilepsy

No history of asthma 

Personal history 

Diet - mixed

Appetite is normal

Bowel and bladder - normal and regular

 No Known allergies

  Addictions - regular alcohol consumption approx 90 ml

Family history

His family members are not having any relevant issues 

General examination

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished

Icterus is absent 

Pedal edema - present (pitting type)

Pallor is present 

No cyanosis, clubbing , lymphadenopathy .

Vitals : 

Temperature- afebrile

Respiratory rate - 28 cpm

Pulse rate - 92 bpm 

BP - 160/100 mm Hg.

Spo2 at room air is 98%

GRBS - 126 mg/dl

SYSTEMIC EXAMINATION: 

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard(vesicular)

Abdominal examination: 

INSPECTION : 

      Shape of abdomen- scaphoid

-No tenderness of abdomen 

• Umblicus - normal
• Movements of abdominal wall - moves with respiration 
• Skin is smooth and shiny

PALPATION : 

No Local rise of temperature

Tenderness absent

Guarding present

Rigidity absent 

hernial orifices normal

Fluid thrill absent

Liver not palpable .

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 

CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++

Gait: normal

Investigations

Serology: 

HIV - negative 

HCV - negative 

HBsAg - negative 

Provisional diagnosis

Chronic kidney disease secondary to NSAIDS?

TREATMENT 

P: T. NICARDIA 10 MG PO BD
     T. NODOSIS 500 MG PO BD

     T. OROFER XT PO BD
      T. SHELCAL PO BD

    INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE

SOAP NOTES : 28/11/22

S:

   SOB subsided 
   Bilateral pitting oedema
O: vitals
     Temperature- afebrile

Pulse rate- 96 b/m

Respiratory rate- 20 cpm

Bp- 150/100 mmhg


A: chronic renal failure secondary to NSAIDS

P: T. NICARDIA 10 MG PO BD
     T. NODOSIS 500 MG PO BD

     T. OROFER XT PO BD
      T. SHELCAL PO BD

    INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE

SOAP NOTES : 29/11/22

S:

   SOB subsided 
   Bilateral pitting oedema
O: vitals
     Temperature- afebrile

Pulse rate- 98 b/m

Respiratory rate- 20 cpm

Bp- 150/100 mmhg


A: chronic renal failure secondary to NSAIDS

P: T. NICARDIA 10 MG PO BD
     T. NODOSIS 500 MG PO BD

     T. OROFER XT PO BD
      T. SHELCAL PO BD

       T. SPOROLACT BD

    INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE

SOAP NOTES : 30/11/22

S:

   SOB subsided 
   Bilateral pitting oedema
O: vitals
     Temperature- afebrile

Pulse rate- 96 b/m

Respiratory rate- 20 cpm

Bp- 160/100 mmhg

GRBS- 128mg%

A: chronic renal failure secondary to NSAIDS

P: T. NICARDIA 10 MG PO BD
     T. NODOSIS 500 MG PO BD

     T. OROFER XT PO BD
      T. SHELCAL PO BD

    INJ ERYTHROPOIETIN 4000 IU S/C WEKLY ONCE