48 yr old male 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 

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