65YO M WITH NSAIDS INDUCED NEPHROPATHY WITH METABOLIC ACIDOSIS AND CKD WITH HTN

December 13, 2021

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Here is the case I have seen:

CASE DISCUSSION

65 year old male patient came to OPD presenting with:

1.) C/o of difficulty breathing while doing daily routine activities since 15 days

2.) C/o on and off swelling in the both legs since 2 years

3.) C/o decreased urine output since 2 months 

3.) C/o decreased appetite

History of Present Illness

-65 year old male, farmer by occupation and capable of completing all of his routine activities without assistance, was apparently asymptomatic 14 years back when he incidentally met with an RTA because of which he sustained lower back ache. He was conservatively treated in hospital for six days and then discharged.

-Following discharge the patient complained of recurrent back ache for which he took NSAIDS for 10 years from nearby hospital along with herbal medication .

-2 years back the pt complained of unceasing bilateral pedal edema for which he went to local hospital and got treated conservatively after which then pedal edema became intermittent in nature.

-2months back he noticed decreased urine output when compared to previous days

-Since 15 days he complained of shortness of breath grade 2 to grade 3

Past History

-K/c/o Hypertension since 1month ( on tab atenolol 10mg,irregular medication)

-Not a k/c/o diabetes mellitus, asthma, epilepsy, CAD .

-No H/o any surgery in the past

-No H/o of similar complaints in the past

Drug History

-NSAIDs since last 10 years for alleviate chronic lower back back post RTA (estimated 1-2 tab/ day of unknown dosage)

-Tab Atenolol 10mg since 1 month (irregular medication)

Personal history

-Diet - mixed 

-Appetite - decreased

-Sleep - adequate 

-Bowel movements : regular 

-Bladder movements : decreased urine output

Family History

-No relevant family history

On Examination 

Patient is conscious, coherent, cooperative

Well built and properly nourished

Pallor-absent

Icterus-absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent

Edema- Bilateral Pedal Edema present

Vitals

Temp- 97.7 F (febrile)

PR- 112

RR-20

BP-150/80mm of Hg

SPO2- 97 at room air

Systemic Examination

Cardiovascular Exam

Inspection

Chest wall is bilaterally symmetrical 

No precordial bulge

No visible pulsations, engorged veins, scars, or sinuses

Palpation

JVP- Normal

Apex Beat- Felt in the left 5th intercostal space in the midclavicular line

Auscultation

S1S2 heard

No murmurs

Respiratory System

Position of the Trachea is central

B/L air entry +

Normal Vesicular Breath Sounds Heard

No added sounds

Per Abdomen

Abdomen is soft, non tender

No signs of organomegaly

Bowel sounds heard

No free fluid

Central Nervous System

Patient is conscious, coherent, cooperative

Speech: Normal

No signs of Meningeal irritation 

Motor and Sensory System: No abnormalities Detected

Reflexes: Normal

Cranial Nerves: Intact

GCS Score- 15/15

Investigations and Findings

Laboratory Investigations:

Radiological Investigations:

-US Abdomen shows Bilateral grade II Chronic Kidney Disease with bilateral simple renal cortical cysts 

Cardiac Work up:

DIAGNOSIS

-65 y/o Male with NSAIDS INDUCED NEPHROPATHY WITH CKD AND METABOLIC ACIDOSIS AND HTN(1MONTH)

TREATMENT

1.)Fluid restriction (<1l/day)

2.)Salt restriction (<2g/day)

     INJ· LASIX 40 mg IV/ TID.

3.)T. NODOSIS 500 MG PO BD

4.)T. OROFER-XR PO OD

5.)T. SHELCAL-CT PO OD

     STRICT I/O MONITORING.

SOAP NOTES

13/12/21

CKD ward: 65 year old Male

S:

C/o pain in bilateral lower limbs

C/o backache

C/o fever

O:

Pt is conscious, coherent, cooperative

BP: 140/90 mmHg

PR: 70 bpm

Temp: febrile

Last Dialysis was done on 10/12/21

K/c/o HTN since 1 mont

A:

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

P: 

1. FLUID RESTRICTION 2l/DAY, SALT RESTRICTION 2g/DAY

2. INJ. PANTOP 40 MG/IV/OD

3. INJ. ZOFER 4 MG/IV/BD

4. INJ LASIX 40MG/IV/BD

5. TAB NODOSIS 550 MG/PO/BD

6. TAB SHELCAL 50P MG/PO

7. TAB PCM 650MG/PO/BD

8. TAB CEFIXIME 200MG/PO/QID

9. TAB ULTRACET PO/QID

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

11. MONITOR VITALS AND URINE INPUT/OUTPUT