A 46 year old female patient was admitted to the female medicine ward with complaints of breathlessness on walking, fever, right pedal oedema, giddiness on walking.

1. CKD STAGE 5
(KIDNEY
FAILURE)
- BY AJITA SADHUKHAN AND REEYA AMIN
- PHARM D. 2ND YEAR

2. PATIENT DEMOGRAPHICS
• GENDER: FEMALE
• AGE: 46 YEARS
• WEIGHT: 65Kg
• HEIGHT: 5Ft4”
• BMI: 24.6
• DATE OF ADMISSION: 30/9/16
• DEPARTMENT: FEMALE MEDICINE WARD
• UNIT: 2

3. COMPLAINTS ON ADMISSION
• C/O BREATHLESSNESS ON WALKING
• C/O FEVER
• C/O RIGHT PEDAL EDEMA
• C/O GIDDINESS ON WALKING
• PHMx: OPERATED ANTERIOR PART OF LEG
• FAMILY Hx: NS
• SOCIAL Hx: N/A
• ALLERGIES: NKA

4. PROVISIONAL DIAGNOSIS
• ? CKD, ? FLUID OVERLOAD

5. DAY 1 : 1 P.M.
• B.P. : 110/70 mmHg
• P.R. : 72 bpm
• SPO2 : 94%
• CVS : S1 S2 +
• P/A : SOFT, NON TENDER
• CNS : CONSCIOUS
• ADV : RENAL DIET, CBC, URINE ANALYSIS, ELECTROLYTE BALANCE, IRON LEVEL, ECG, USG ABDOMEN
AND PELVIS
• Rx : AS PER CHART

6. DAY 1 : 7 P.M.
• G.C. : STABLE
• B.P. : 110/70 mmHg
• P.R. : 72 bpm
• SPO2 : 99%
• R.S. : NORMAL
• CVS : S1 S2 +
• CNS : CONSCIOUS
• P/A : SOFT

7. DAY 1 : 9 P.M.
• C/O : DRY COUGH
• G.C. : STABLE
• B.P. : 150/90 mmHg
• P.R. : 72 bpm
• SPO2 : 98%
• R.S. : NORMAL
• CVS : S1 S2 +
• CNS : CONSCIOUS
• P/A : SOFT
• ADV : Syp. DPC 2tsf TDS

8. COMPLETE BLOOD COUNT
TEST RESULT REFERENCE RANGE
HAEMOGLOBIN 9.8 g/dl 12.5-16 g/dl
TOTAL WBC COUNT 4800 /micro litre 4000-10500 /micro litre
NEUTROPHILS 74 % 50-70 %
EOSINIPHILS 03 % 0-7 %
BASOPHILS 00 % <1 %
LYMPHOCYTES 19 % 20-40 %
MONOCYTES 04 % <10 %
RBC COUNT 4.01 millions/microL 4.20-5.40 millions/micro litre
HEMATOCRIT (PCV) 27.9 % 37-47 %
MCV 69.5 fl 78-100 fl
MCH 24.4 pg 27-31 pg
MCHC 35.2 g/dl 32-36 g/dl
RDW-CV 15.7 % 11-14.6 %
PLATELET COUNT 262000 /micro litre 1,50,000-4,50,000 /cumm
MEAN PLATELET VOLUME 8.0 fl 6.5-12.0 fl
PCT 0.21 %
PDW 12.2

9. URINE ANALYSIS
• PHYSICAL EXAMINATION: CHEMICAL EXAMINATION:
COLOUR : PALE YELLOW ALBUMIN : 3+
APPEARANCE : TURBID GLUCOSE : NEGATIVE
REFLECTION : 8.0 UROBILINOGEN : NORMAL
SPECIFIC GRAVITY : 1.015 BILIRUBIN : NEGATIVE
KETONE : NEGATIVE
BLOOD : ABSENT
NITRATES : POSITIVE

10. URINE ANALYSIS (CONTD.)
TEST RESULT REFERENCE RANGE
PUS CELLS 10-15/HPF 0-10hpf
RBCs ABSENT 0-10hpf
EPITHELIAL CELLS 2-3/HPF ABSENT
CASTS ABSENT
CRYSTALS TRIPLE PHOSPHATE (++++)
BACTERIA PRSESNT (++++)
TRICHOMONAS ABSENT
MICROSCOPIC EXAMINATION:

11. LIVER FUNTION TEST:
TEST RESULT REF. RANGE
TOTAL 0.3 mg/dl 0.3-1.2 mg/dl
DIRECT 0.1 mg/dl 0.0-0.4 mg/dl
INDIRECT 0.2 mg/dl 0.0-0.6 mg/dl
Se. BILIRUBIN:
S.G.O.T. (AST):
S.G.P.T. (ALT):
TEST RESULT REF. RANGE
SERUM GLUTAMATE PYRUVIC
TRANSAMINASE
19 U/L 0.0-49 U/L
TEST RESULT REF. RANGE
SERUM GLUTAMATE
OXALOACETIC TRANSAMINASE
14 U/L 0.0-40 U/L

12. LIVER FUNTION TEST (CONTD) :
TEST RESULT REF. RANGE
TOTAL PROTEIN 5.6 g/dl 6.3-8.3 g/dl
ALBUMIN 3.7 g/dl 3.6-4.5 g/dl
GLOBULIN 1.9 g/dl 2.7-3.5 g/dl
ALBUMIN GLOBULIN RATIO 1.95
Se. ALP:
Se. PROTEIN:
TEST RESULT REF. RANGE
ALKALINE PHOSPHATASE 149 U/L ADULTS: <270 U/L

13. SERUM ELECTROLYTES:
TEST RESULT REF. RANGE
Se. SODIUM 134 mmol/L 135-145 mmol/L
Se. POTASSIUM 5.2 mmol/L 3.5-5.0 mmol/L
Se. CHLORIDE 107 mmol/L 98-107 mmol/L
SERUM CALCIUM LEVEL:
TEST RESULT REF. RANGE
Se. CALCIUM 5.9 mg/dl 9.0-10.5 mg/dl

14. BIOCHEMISTRY REPORT:
TEST RESULT REF. RANGE
Se, CREATININE 7.2 mg/dl < 1.5 mg/dl
Se. UREA 100 mg/dl 15-40 mg/dl
GFR VALUE: 10.02 ml/min/1.73 m2

15. HIV I, II & HBSAQ
• HIV I : NEGATIVE
• HIV II : NEGATIVE
• HBsAq : NEGATIVE
HEPATITIS C VIRUS : (RAPID CARD TEST)
• HEPATITIS C VIRUS : NEGATIVE

16. ANAEMIA PROFILE
TEST RESULT UNIT REF. RANGE
Se. iron level 78.9 mcg/dl 50-170 mcg/dl
Se. T.I.B.C. ( total iron
binding capacity)
285.9 mcg/dl 250-400 mcg/dl

17. USG REPORT ( ABDOMINAL AND PELVIC ULTRASOUND)
• LIVER: Liver size NORMAL. The hepatic parenchymal echo texture is NORMAL. Intrahepatic and the extra
hepatic biliary ducts are not dilated. Hepatic veins and the portal vein are normal. No focal lesion is seen in
the liver.
• GALL BLADDER: Well distended. No calculus/sludge is seen. The wall thickness is normal. No peri-cholecystic
fluid.
• COMMON BILE DUCT: Normal in diameter.
• SPLEEN: Size 11cm. Normal Echopattern. No focal lesion is seen.
• PANCREAS: The echo texture appears normal. No focal lesion is seen. The pancreatic duct is not dilated.
• KIDNEYS: Both kidneys are normal in size. Normally situated. There is adequate cortico-medullary
differentiation. Rt. Kidney : (6.4*3.4) cm & Lt. kidney : (7.6*3.6)cm. No evidence of calculus, SOL or
hydronephoresis is seen in both kidneys. Both kidneys show red echogenicity & CMD attenuated.
• PANCREATIC REGION: Aorta and the IVC appear normal. No lymph node enlargement is seen.
• OTHERS: There is no ascites.
• BLADDER: Empty. Uterus not seen (H/O hystectomy)
• CONCLUSION: B/L renal parenchymal disease.

18. ECG REPORT

19. MEDICATION CHART DAY 1
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. CEFOPERAZONE +
SULBACTUM
1.5 g in 100 ml NS IV BID BACTERIAL INFECTIONS + SOFT
TISSUE INFECTIONS,
PYELONEPHRITIS
Inj. PANTOPRAZOLE 80mg IV BID GERD
Syp. DISODIUM HYDROGEN
CITRATE
2tsf in half glass of
water
P/O TDS URINARY TRACT INFECTIONS
(REDUCE URIC ACID STONES)
Syp. DPC
(DEXTROMETHORPHAN +
PHENYLPROPANOLAMINE +
CHLORPHENIRAMINE)
2 tsf P/O TDS DRY COUGH + CONTROL OF
URINARY INCONTINENCE +
DYSPNEA AND COMMON COLD

20. DAY 2 :
9:10 a.m.
• C/O : GIDDINESS
• T/P/R : NORMAL
• P.R. : 95 bpm
• B.P. : 180/100 mmHg
• RS : NAD
• CVS : NAD
• CNS : NAD
10 a.m.
• B.P. : 160/100 mmHg
11 a.m.
• I/O RATIO : 1100/1400
• ADV : URINE ANALYSIS
• Rx : AS PER CHART

21. SERUM BICARBONATE REPORT:
ANAEMIA PROFILE:
TEST RESULT UNIT REF. RANGE
BICARBONATE 14.1 mEq/L 22-29mEq/L
TEST RESULT UNIT REF. RANGE
Se. FERRITIN 16.2 mg/mL F: 11-306.8 mg/ml
M: 23.9-336.2 mg/dl

22. MEDICATION CHART DAY 2
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. CEFOPERAZONE +
SULBACTUM
1.5 g in 100 ml NS IV BID BACTERIAL INFECTIONS + SOFT TISSUE
INFECTIONS, PYELONEPHRITIS
Inj. PANTOPRAZOLE 80mg IV BID GERD
Syp. DISODIUM HYDROGEN
CITRATE
2tsf in half glass of
water
P/O TDS URINARY TRACT INFECTIONS (REDUCE
URIC ACID STONES)
Syp. DPC
(DEXTROMETHORPHAN +
PHENYLPROPANOLAMINE +
CHLORPHENIRAMINE)
2 tsf P/O TDS DRY COUGH + CONTROL OF URINARY
INCONTINENCE + DYSPNEA AND
COMMON COLD
Tab. CLONIDINE 0.1mg P/O SOS HYPERTENSION
Tab. FOLIC ACID + PYRIDOXINE
+ MECOBALAMIN
20mg P/O 1-1-1 AMAEMIA ( MEGALOBLASTIC)
Tab. FOLIC ACID 2mg P/O 1-0-1 VITAMIN SUPPLEMENT
Syp. IRON (III) HYDROXIDE
POLYMALTOSE COMPLEX +
FOLIC ACID ( VITAMIN B9)
1mg P/O ONCE DAILY IRON DEFICIENCY ANAEMIA + VITAMIN
SUPPLEMENT

23. DAY 3
6 a.m.
• GC STABLE
• T/P/R : NORMAL
• SPO2 : 98%
• B.P. : 140/90 mmHg
• RS : NAD
• CVS : NAD
• CNS : CONSCIOUS
• P/A : SOFT
9 a.m.
• B.P. : 130/80 mmHg
7 p.m.
• B.P. : 130/90 mmHg
• I/O RATIO : 1100/1300
• ADV : URINE ANALYSIS
• Rx: AS PER CHART

24. MEDICATION CHART DAY 3
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. CEFOPERAZONE +
SULBACTUM
1.5 g in 100 ml NS IV BID BACTERIAL INFECTIONS
+ SOFT TISSUE
INFECTIONS,
PYELONEPHRITIS
Inj. PANTOPRAZOLE 40mg IV BID GERD
Tab. CLONIDINE 0.1mg P/O SOS HYPERTENSION
Tab. FOLIC ACID +
PYRIDOXINE +
MECOBALAMIN
20mg P/O 1-1-1 AMAEMIA
(MEGALOBLASTIC)
Tab. FOLIC ACID 2mg P/O 1-0-1 VITAMIN SUPPLEMENT
Syp. DISODIUM
HYDROGEN CITRATE
2tsf in half glass of
water
P/O TDS URINARY TRACT
INFECTIONS (REDUCE
URIC ACID STONES)
Syp. DPC
(DEXTROMETHORPHAN
+
PHENYLPROPANOLAMI
NE +
2 tsf P/O TDS DRY COUGH + CONTROL
OF URINARY
INCONTINENCE +
DYSPNEA AND
COMMON COLD

25. DAY 4
6 a.m.
• P.R. : 90 bpm
• B.P. : 150/100 mmHg
• SPO2 : 98%
8:55 a.m.
• C/O GIDDINESS
• C/O VOMITTING YESTERDAY
• B.P. : 120/90 mmHg
• P.R. : 98 bpm
• SPO2 : 99%
• RS : NAD
• CVS : NAD
• CNS : NAD
• I/O RATIO : 1100/1650

26. DAY 4
6 p.m.
• T/P/R : NORMAL
• B.P. : 140/90 mmHg
• P.R. : 98 bpm
• SPO2 : 99%
• RS : NAD
• CVS : NAD
• CNS : NAD
• SPO2 : 98%
9 p.m.
• P.R. : 90 bpm
• B.P. : 156/90 mmHg
• SPO2 : 99%
• RS : NAD
• CVS : NAD
• CNS : NAD
• ADV : CONTINUE THE SAME TREATMENT

27. MEDICATION CHART DAY 4
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. CEFOPERAZONE +
SULBACTUM
1.5 g in 100 ml NS IV BID BACTERIAL INFECTIONS
+ SOFT TISSUE
INFECTIONS,
PYELONEPHRITIS
Inj. PANTOPRAZOLE 40mg IV BID GERD
Tab. CLONIDINE 1mg P/O SOS HYPERTENSION
Tab. FOLIC ACID +
PYRIDOXINE +
MECOBALAMIN
20mg P/O 1-1-1 AMAEMIA (
MEGALOBLASTIC)
Tab. FOLIC ACID 2mg P/O 1-0-1 VITAMIN SUPPLEMENT
Syp. DISODIUM
HYDROGEN CITRATE
2tsf in half glass of
water
P/O 2-2-2 URINARY TRACT
INFECTIONS (REDUCE
URIC ACID STONES)
Syp. DPC
(DEXTROMETHORPHAN
+
PHENYLPROPANOLAMI
2 tsf P/O 2-2-2 DRY COUGH + CONTROL
OF URINARY
INCONTINENCE +
DYSPNEA AND

28. DAY 5
9:05 a.m.
• B.P. : 150/100 mmHg
• P.R. : 99 bpm
• SPO2 : 97%
• RS : B/L CREPTS +
• CVS : NAD
• CNS : NAD
• P/A : SOFT
• L/E : Rt. SIDE PEDAL EDEMA ++
11:30 a.m.
• I/O RATIO : 1200/1400
• ADV : URINE ANALYSIS, HCO3-, Na+, K+, Se. CREATININE

29. DAY 5
6:30 p.m.
• O/E : T/P/R : NORMAL
• B.P. : 150/90 mmHg
• P.R. : 104 bpm
• SPO2 : 98%
• RS : NAD
• CVS : NAD
• CNS : NAD
• ADV : CST

30. URINE ANALYSIS:
• PHYSICAL EXAMINATION: CHEMICAL EXAMINATION:
COLOUR : PALE YELLOW ALBUMIN : 3+
APPEARANCE : SLIGHTLY TURBID GLUCOSE : NEGATIVE
REFLECTION : 8.0 UROBILINOGEN : NORMAL
SPECIFIC GRAVITY : 1.010 BILIRUBIN : NEGATIVE
KETONE : NEGATIVE
BLOOD : ABSENT
NITRATES : NEGATIVE

31. URINE ANALYSIS (CONTD.):
• MICROSCOPIC EXAMINATION:
TEST RESULT REFERENCE RANGE
PUS CELLS 6-8/HPF 0-10hpf
RBCs ABSENT 0-10hpf
EPITHELIAL CELLS 3-5/HPF ABSENT
CASTS ABSENT
CRYSTALS TRIPLE PHOSPHATE
BACTERIA PRSESNT (3+)
TRICHOMONAS ABSENT

32. SERUM BICARBONATE
TEST RESULT REF. RANGE
Se. SODIUM 124 mEq/L 135-145 mEq/L
Se. POTASSIUM 3.9 mEq/L 3.5-5.0 mEq/L
Se. CREATININE 7.2 mg/dl < 1.5 mg/dl
TEST RESULT UNIT REF. RANGE
BICARBONATE 19.1 mEq/L 22-29mEq/L
BIOCHEMISTRY REPORT:
GFR VALUE: 10.02 ml/min/1.73 m2

33. MEDICATION CHART DAY 5
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. CEFOPERAZONE +
SULBACTUM
1.5 g in 100 ml NS IV BID BACTERIAL INFECTIONS
+SOFT TISSUE
INFECTIONS,
PYELONEPHRITIS
Inj. PANTOPRAZOLE 40mg IV BID GERD
Tab. CLONIDINE 0.1mg P/O SOS HYPERTENSION
Tab. FOLIC ACID +
PYRIDOXINE +
MECOBALAMIN
20mg P/O 1-1-1 AMAEMIA (
MEGALOBLASTIC)
Tab. FOLIC ACID 2mg P/O 1-0-1 VITAMIN SUPPLEMENT
Syp. DISODIUM
HYDROGEN CITRATE
2tsf in half glass of
water
P/O 2-2-2 URINARY TRACT
INFECTIONS (REDUCE
URIC ACID STONES)
Syp. DPC
(DEXTROMETHORPHAN
+
PHENYLPROPANOLAMI
2 tsf P/O 2-2-2 DRY COUGH + CONTROL
OF URINARY
INCONTINENCE +
DYSPNEA AND

34. DAY 6
6 a.m.
• P.R. : 86 bpm
• B.P. : 160/100 mmHg
• SPO2 : 98%
9:00 a.m.
• C/O NAUSEA
• B.P. : 150/80 mmHg
• P.R. : 101 bpm
• SPO2 : 94%
• RS : NAD
• CVS : NAD
• CNS : NAD
10 a.m.
• I/O RATIO : 1100/1400
• ADV : URINE ANALYSIS, HCO3-, Na+, K+, Se. CREATININE, CONTINUE SAME TREATMENT

35. MEDICATION CHART DAY 6
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. CEFOPERAZONE +
SULBACTUM
1.5 g in 100 ml NS IV BID BACTERIAL INFECTIONS
+SOFT TISSUE
INFECTIONS,
PYELONEPHRITIS
Inj. PANTOPRAZOLE 40mg IV BID GERD
Tab. CLONIDINE 0.1mg P/O SOS HYPERTENSION
Tab. FOLIC ACID +
PYRIDOXINE +
MECOBALAMIN
20mg P/O 1-1-1 AMAEMIA (
MEGALOBLASTIC)
Tab. FOLIC ACID 2mg P/O 1-0-1 VITAMIN SUPPLEMENT
Syp. DISODIUM
HYDROGEN CITRATE
2tsf in half glass of
water
P/O 2-2-2 URINARY TRACT
INFECTIONS (REDUCE
URIC ACID STONES)
Syp. DPC
(DEXTROMETHORPHAN
+
PHENYLPROPANOLAMI
2 tsf P/O 2-2-2 DRY COUGH + CONTROL
OF URINARY
INCONTINENCE +
DYSPNEA AND

36. DAY 7
9:00 a.m.
• GC STABLE
• O/E : T/P/R : NORMAL
• B.P. : 160/90 mmHg
• P.R. : 104 bpm
• SPO2 : 98%
• RS : NAD
• CVS : NAD
• CNS : CONSCIOUS
• P/A : SOFT
• URINE AND STOOL : PASSED
• I/O RATIO : 1400/1600
• ADV : URINE ANALYSIS, HCO3-, Na+, K+, Se. CREATININE, NEPHROLOGIST REFERENCE

37. DAY 7
7 p.m.
C/O NONE
O/E : T/P/R : NORMAL
B.P. : 160/100 mmHg
P.R. : 86 bpm
SPO2 : 98%
RS : NAD
CVS : NAD
CNS : NAD
ADV : CST
9 p.m.
GC STABLE
O/E : T/P/R : NORMAL
B.P. : 160/90 mmHg
SPO2 : 98%
RS : NAD
CVS : NAD
CNS : CONSCIOUS
P/A : SOFT

38. BIOCHEMISTRY REPORT:
TEST RESULT REF. RANGE
Se. SODIUM 125 mEq/L 135-145 mEq/L
Se. POTASSIUM 3.5 mEq/L 3.5-5.0 mEq/L
Se. CREATININE 7.2 mg/dl < 1.5 mg/dl
GFR VALUE: 10.02 ml/min/1.73 m2

39. SERUM BICARBONATE REPORT
TEST RESULT UNIT REF. RANGE
BICARBONATE 17.8 mEq/L 22-29mEq/L

40. MEDICATION CHART DAY 7
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. CEFOPERAZONE +
SULBACTUM
1.5 g in 100 ml NS IV BID BACTERIAL INFECTIONS
+SOFT TISSUE
INFECTIONS,
PYELONEPHRITIS
Inj. PANTOPRAZOLE 40mg IV BID GERD
Tab. CLONIDINE 0.1mg P/O SOS HYPERTENSION
Tab. FOLIC ACID +
PYRIDOXINE +
MECOBALAMIN
20mg P/O 1-1-1 AMAEMIA (
MEGALOBLASTIC)
Tab. FOLIC ACID 2mg P/O 1-0-1 VITAMIN SUPPLEMENT
Syp. DISODIUM
HYDROGEN CITRATE
2tsf in half glass of
water
P/O 2-2-2 URINARY TRACT
INFECTIONS (REDUCE
URIC ACID STONES)
Syp. DPC
(DEXTROMETHORPHAN
+
PHENYLPROPANOLAMI
2 tsf P/O 2-2-2 DRY COUGH + CONTROL
OF URINARY
INCONTINENCE +
DYSPNEA AND

41. DAY 8
6:00 a.m.
• GC STABLE
• O/E : T/P/R : NORMAL
• B.P. : 160/90 mmHg
• P.R. : 104 bpm
• SPO2 : 98%
• RS : NAD
• CVS : NAD
• CNS : CONSCIOUS
• P/A : SOFT
• URINE AND STOOL : PASSED

42. DAY 8
8:50 p.m.
• NO HEADACHE AND GIDDINESS
• P.R. : 90 bpm
• I/O RATIO : 800/1200
• B.P. : 138/84 mmHg
• SPO2 : 99%
• RS : NAD
• CVS : NAD
• CNS : NAD
• ADV : CST

43. MEDICATION CHART DAY 8
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. CEFOPERAZONE +
SULBACTUM
1.5 g in 100 ml NS IV BID BACTERIAL INFECTIONS
+SOFT TISSUE
INFECTIONS,
PYELONEPHRITIS
Inj. PANTOPRAZOLE 40mg IV BID GERD
Tab. CLONIDINE 0.1mg P/O SOS HYPERTENSION
Tab. FOLIC ACID +
PYRIDOXINE +
MECOBALAMIN
20mg P/O 1-1-1 AMAEMIA
(MEGALOBLASTIC)
Tab. FOLIC ACID 2mg P/O 1-0-1 VITAMIN SUPPLEMENT
Syp. DISODIUM
HYDROGEN CITRATE
2tsf in half glass of
water
P/O 2-2-2 URINARY TRACT
INFECTIONS (REDUCE
URIC ACID STONES)
Syp. DPC
(DEXTROMETHORPHAN
+
PHENYLPROPANOLAMI
2 tsf P/O 2-2-2 DRY COUGH + CONTROL
OF URINARY
INCONTINENCE +
DYSPNEA AND

44. PHARMACEUTICAL CARE PLAN:
SUBJECTIVE EVIDENCE OBJECTIVE EVIDENCE
• BREATHLESSNESS ON WALKING
• FEVER
• RIGHT PEDAL EDEMA
• GIDDINESS ON WALKING
• DRY COUGH
• VOMITING
• NAUSEA
• B.P. : 180/100 mmHg
• PULSE: 104 bpm
• R.S. : B/L CREPTS
• Hb. 9.8 g/dl
• NEUTROPHILS : 74%
• LYMPHOCYTES : 19%
• RBC COUNT : 4.01 millions/micro litre
• HEMATOCRIT(PCV) : 27.9%
• MCV : 69.5 fl
• MCH : 24.4 pg
• RDW-CV : 15.7%
• URINE ANALYSIS – PHYSICAL, CHEMICAL, MICROSCOPIC
• LIVER FUNCTION TEST – BILIRUBIN, ALT, AST, ALP, PROTEIN
• SERUM ELECTROLYTES
• SERUM CALCIUM LEVEL
• BIOCHEMISTRY REPORT – CREATININE(GFR:10.02), UREA
• HIV I, II, HBsAq
• HEPATITIS C VIRUS
• AMAEMIA PROFILE
• USG (ABDOMINAL AND PELVIC REGION)
• ECG
• SERUM BICARBONATE

45. FINAL DIAGNOSIS:
CKD STAGE 5 (KIDNEY FAILURE)

46. GOALS OF TREATMENT:
• TO REDUCE ALL SIGNS AND SYMPTOMS (DYPSNEA, GIDDINESS, FEVER, PEDAL EDEMA, DRY COUGH,
NAUSEA, VOMITING)
• TO MAINTAIN BLOOD PRESSURE WITHIN THE NORMAL RANGE → 140/90 mmHg
• DELAYING THE PROGRESSION OF CKD
• DIAGNOSING AND TREATING THE PATHOLOGIC MANAGEMENT OF CKD (ANAEMIA,
HYPERPHOSPHATEMIA, HYPOCALCEMIA, VOLUME OVERLOAD, UREMIC MANIFESTATIONS,
CARDIOVASCULAR COMCLICATIONS)
• TIMELY PLANNING FOR LONG-TERM RENAL REPLACEMENT THERAPY
• EARLY REFERRAL TO A NEPHROLOGIST
• TREATMENT OF THE UNDERLYING CAUSE IF POSSIBLE

47. TREATMENT OPTIONS
NON-PHARMACOLOGICAL TREATMENT:
• RENAL DIET
• HAEMODIALYSIS
• RENAL REPLACEMENT THERAPY

48. TREATMENT OPTIONS ( CONTD)
PHARMACOLOGICAL TREATMENT:
• HIGH BLOOD PRESSURE MEDICATIONS (ACE INHIBITORS/ARBs + BETA BLOCKERS/CCBs)
• MEDICATIONS TO LOWER CHOLESTEROL (STATINS)
• MEDICATIONS TO TREAT ANAEMIA (IRON SUPPLEMENTS)
• MEDICATIONS TO RELIEVE SWELLING (LOOP DIURETICS)
• MEDICATIONS TO INCREASE CALCIUM LEVEL (CALCIUM SUPPLEMENTS)

49. MONITORING PARAMETERS
FOR DISEASE:
• B.P.
• P.R.
• I/O RATIO
• R.S.
• SPO2
• CVS
• P/A
• LIPID PROFILE
• URINE ANALYSIS
• GFR
• LIVER FUNCTION TEST
• BLOOD GLUCOSE LEVEL, HbA1c
• USG
• ECG
• ANAEMIA PROFILE

50. MONITORING PARAMETERS (CONTD.):
FOR DRUGS:
• BODY WEIGHT
• ECG
• B.P.
• BLOOD ROUTINE
• LIVER FUNCTION TEST
• URINE ANALYSIS
• ELECTROLYTE BALANCE
• SERUM CALCIUM LEVEL
• SERUM BICARBONATE LEVEL
• BIOCHEMISTRY ROUTINE (GFR)

51. GOALS ACHIEVED
• GENERAL CONDITION STABILIZED
• BLOOD PRESSURE IS CONTROLLED TO TARGETTED LEVEL
• GIDDINESS REDUCED
• HEADACHE REDUCED
• NO FURTHER COMPLAINTS

52. PROBLEMS IDENTIFIED
• BLOOD GLUCOSE TEST NOT DONE
• HbA1C NOT DONE
• LIPID PROFILE NOT DONE
• FUNDOSCOPY NOT DONE
• DIALYSIS NOT DONE
• PEDAL EDEMA NOT REDUCED
• PROTEINURIA NO
• DRUG INTERACTIONS: CONCURRENT USE OF SULBACTUM AND PANTOPRAZOLE MAY RESULT IN LOSS OF
SULBACTUM EFFICACY (MODERATE)

53. PATIENT COUNSELLING
ABOUT DISEASE:
• STAGE 5 CKD IS THE END STAGE RENAL DISEASE WITH A GLOMERULAR FILTRATION RATE OF 15 ml/min OR LESS.
• BECAUSE THE KIDNEYS ARE NO LONGER ABLE TO REMOVE WASTE AND FLUIDS FROM THE BODY, TOXINS BUILD UP IN THE
BLOOD, CAUSING AN OVERALL ILL FEELING.
• KIDNEYS ALSO HAVE OTHER FUNCTIONS THEY ARE NOT ABLE TO PERFORM SUCH AS REGULATING BLOOD PRESSURE,
PRODUCING THE HORMONE THAT HELPS IN MAKING RBCs AND ACTIVATING VITAMIN D FOR HEALTHY BONES.
• AT THIS ADVANCED STAGE OF KIDNEY DISEASE, THE KIDNEYS HAVE NEARLY LOST ALL THEIR ABILITY TO DO THEIR JOB
EFFECTIVELY, AND EVENTUALLY DIALYSIS OR A KIDNEY TRANSPLANT IS NEEDED TO LIVE.

54. PATIENT COUNSELLING ( CONTD.)
ABOUT MEDICATION:
• DOSE OF DRUGS
• FREQUENCY OF DOSE
• ROUTE OF ADMINISTRATION SUCH AS I.V, I.M., T/D,S/C, P.O. S/L.
• COUNSELLING REGARDING OVERDOSE (MAY CAUSE TOXICITY), UNDERDOSE (SUBMAXIMAL OR NO RESPONSE)
AND MISSING OF DOSE OF MEDICATION. E.g. IF A DOSE IS MISSED, THEN THE PATIENT IS TO BE ADVISED TO
GO FOR THE NEXT DOSE, OTHERWISE TOXICITY OF DRUG MAY OCCUR.
• CONTRAINDICATIONS
• DRUG INTERACTIONS (DRUG-DRUG, DRUG-FOOD)

55. PATIENT COUNSELLING ( CONTD.)
LIFESTYLE MODIFICATIONS
• RENAL DIET (INCLUDING GRAINS, FRUITS AND VEGETABLES, BUT LIMITING OR AVOIDING WHOLE GRAINS AND CERTAIN
FRUITS AND VEGETABLES THAT ARE HIGH IN PHOSPHOROUS OR POTASSIUM)
• LIMITING CHOLESTEROL IN DIET
• LIMIT INTAKE OF SODIUM IN DIET
• MAINTAINANCE OF BODY WEIGHT
• MODERATE PHYSICAL ACTIVITY
• AVOID STRESS
• LIMITING FLUID INTAKE (1.2-1.5L/DAY)