Case history 4

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December 14th, 

A 65 yr old male patient presented to the opd with chief complaints of shortness of breathe since 15 days, bilateral pedal oedema and reduced urine output since 2 months and decreased appetite. 

65 year old male who is farmer by occupation 

 was apparently asymptomatic 14 years back doing all his routine activities and then he met with an RTA and sustain low back ache for which he was conservatively treated for six days and then discharged which is followed by recurrent back ache for which he took NSAIDS for 10 years in nearby hospital followed by herbal medication .

Two years back he noticed bilateral pedal edema and went to local hospital and treated conservatively and then pedal edema is on and off.

2months back he noticed decreased urine output

Since 15 days he complain of shortness of breath grade 2 to grade 3

     

History of past illness:

Hypertension since 1month ( on tab atenolol 10mg,irregular medication)

Not a known case of diabetes mellitus,asthma,epilepsy,CAD

 Personal history : 

Diet - mixed 

Appetite - decreased

Sleep - adequate 

Bowel movements : regular .

Bladder movements : decreased urine output

Ocassional drinker

Smoking habit is present. 

Vitals:

Temp- 97.7 F

PR- 112

RR-20

BP-150/80mm of Hg

SPO2- 97 at room air

CVS: S1,S2 heard 

RS: BAE +,NVBS 

P/A: soft , NonTender

Bowel sounds heard

CNS : pt is conscious,coherent,cooperative,NAD.

DIAGNOSIS:NSAIDS INDUCED NEPHROPATHY WITH CKD WITH METABOLIC ACIDOSIS WITH HTN(1MONTH)

Treatment:

Fluid restriction (<1l/day)

Salt restriction (<2g/day)

INJ· LASIX 40 mg IV/ TID.

T. NODOSIS 500 MG PO BD

T. OROFER-XR PO OD

T. SHELCAL-CT PO OD

STRICT I/O MONITORING.

Soap notes 

S:

C/o pain in bilateral lower limbs.

C/0 backache 

C/0 fever

O:

Pt is c/c/c

Bp:140/90mmhg

PR: 78bpm

Temp:febrile

Last dialysis was done on 10/12/21.

K/c/o HTN since 1month.

A:

CKD secondary to ?NSAID abuse,?NSAID induced nephropathy,with rheumatoid arthritis, K/c/o HTN since 1 month.

P:

1.FLUID RESTRICTION 2L/DAY,

SALT RESTRICTION 2G/DAY.

2. TAB.NODOSIS 550 MG/PO/BD 

3..TAB.SHELCAL 50P MG/PO

4. TAB PCM 650MG/PO/BD.

5. TAB ULTRACET PO/QID 

6.Tab Methotrexate 7.5mg weekly once 

7. Tab Folic acid 5mg on every alternative day

8. INJ.NEOMAL 1 GM/IV IF TEMP > 101.1 F

9. MONITOR VITALS AND URINE I/O.