A 62 YR OLD MALE WITH CKD

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Case:

A 62 yr male with chief complaints

-Loss of appetite from 1 month

-SOB since 20 days

-Cough since 15 days 

History of present Illness:

-C/o shortness of breath since 20 days grade 4 ,no pnd and no orthopnea

-Cough since 15 days non productive,no haemoptysis.

Past history:

K/C/O HTN from 5 years not on regular medication,DM from 5 yrs not on regular medication

General Examination:

Patient is conscious, coherent, co-operative

Well oriented to time, place and person

Moderately built and nourished

No pallor, icterus, cyanosis , clubbing, pedal oedema, lymphadenopathy

Vitals:

PR:88bpm

BP:160/90mm Hg

RR:26 cpm

Temp:98.7F

Systemic Examination:

CVS: S1S2 Present

RS: BAE Present,NVBS

P/A: Soft, non tender

CNS:NAD

Investigations:

Provisional Diagnosis:

CKD on MHD with diabetic nephropathy,K/C/O DM and HTN

Treatment:

1)Salt and water restriction

2)INJ.CEFTRIAXONE 500 MG IV/BD

3)INJ.LASIX 40 MG IV/BD

4)INJ.ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE

5)T.OROFER XT PO/OD

6)T.BIO D3 PO/OD

7) NEB.DUOLIN AND BUDECORT 6 th hrly

8)T.MET XL 50 MG PO/OD