CKD secondary to NSAID abuse
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 29 year male came to opd with chief complaints of
Bilateral pain in lower limbs upto knee since 20 days
HOPI
Patient was apparently asymptomatic 3 years ago then developed severe sudden pain in right lower abdomen for which he went to local hospital and was diagnosed to have renal calculus of 4 - 6 mm and got treated for it
6 months later patient developed pain in lower limbs bilaterally for which he visited a local doctor and was tested with high uric acid levels for which he got treated
followed by this he was intermittently having lower limb pain for which he was having acyclophenac whenever he was having episodes of pain
Since 20 days pain wasn't reliving on medication and he got admitted to a local hospital. his creatinine levels were 8.2 for which he was referred to our hospital
Past history
3 years ago he had lower abdomen pain diagnosed renal stones of 4 mm size - relieved on medication,
Not a known case of diabetes , hypertension ,asthma ,tb,cardiovascular , diseases.
Personal history
Diet : mixed
Appetite normal
Sleep : inadequate due to pain since 20days
Bowel and bladder movements regular
No allergies
Occasional alcohol consumption
Chronic smoker since 6 years ( stopped 8 months back)
TREATMENT HISTORY
H/o usage of NSAIDs for pain since 2 yrs
FAMILY HISTORY
Not significant
General examination
Patient was conscious coherent and cooperative
Moderately built , moderately nourished
Pallor +
No icterus ,cyanosis, clubbing lymadenopathy,edema.
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Vitals
BP -140/80
RR - 14/min
Temp - 98F
Pulse rate - 78bpm
Spo2 98percent
Grbs - 134 mg%
SYSTEMIC EXAMINATION
Respiratory examination
Dyspnoea: No
Wheeze: No
Position of trachea: Central
Breath sounds: Vesicular
Adventitious sounds : No
ABDOMEN
Shape - Scaphoid , inverted umbilicus, no engorged veins, no scars
No tenderness, no palpable mass, No Fluid
No bruits heard
Liver not palpable
Spleen not palpable or any
CNS Examination
Conscious coherent cooperative
Higher mental functions intact
No signs of meningitis
Cranial nerves, motor system, sensory system Normal.
Investigations
INVESTIGATION
HIV - non reactive
HBsAg - negative
RBS - 114 mg/dl
Blood urea - 176 mg/dl
Serum creatinine - 7.8mg/dl
PROVISIONAL DIAGNOSIS
CHRONIC KIDNEY DISEASE secondary to NSAID abuse
1/12/23
S -
O - patient is concious, coherent, cooperative.
Temp - afebrile
BP - 120/80 mm Hg
PR - 78 bpm
RR - 18 cpm
CVS - S1, S2 heard
RS - BAE+
P/A - soft, non tender
CNS - no focal neurological deficits
A - CKD secondary to NSAID abuse
P -
Fluid restriction < 1.5L/day
Salt restriction <2g/day
T. Nodosis 500mg PO/BD
T. Orofer PO/OD
T. Shelcal PO/OD
T. LASIX 10mg PO/BD
Monitor vitals
TREATMENT
1) salt restriction <2 g /day
2) fluid restriction <1.5L /day
3) T.NODOSIS 500mg PO/BD
4) T.OROFER-XT PO/OD
5) T.SHELCAL - CT PO/OD
6) T.CAP BIO D3 60,000IU units per weekly
7) T.LASIX 10 mg PO/BD
7) moniter vitals 4 th hrly
