65 year old male with SOB, NAUSEA
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Patient C/O loss of appetite since 10days
C/O SOB since 5 days
C/O nausea since 10days
HOPI-
Patient was apparently asymptomatic 5 months back and then developed swelling of both legs.
H/O HTN since 5 years
Not K/C/O DM.
O/E-
PR-90bpm
TEMP-100 F
BP- 130/60mmhg
RR- 20cpm
SpO2- 96%@RA
GRBS- 106 mg%
CVS-S1 S2+
RS- BAE+, NVBS
CNS- NAD
P/A- Soft, non tender
13/05/2022
RBS- 101 MG/DL
BLOOD UREA-114 MG/DL
S. CREATININE- 6.1 MG/DL
CUE-
ALBUMIN PRESENT
CBP-
HB- 7.3
TLC- 21,700
PLT- 4.58
PROVISIONAL DIAGNOSIS- CKD
TREATMENT-
1. INJ. CEFTRIAXONE + SALBACTAM 1.5 GM IV/BD
2. TAB. LASIX 40MG PO/BD
3. TAB. NICARDIA 30 MG BD
4. TAB. PANTOP PO/OD
5. TAB. NODOSIS 500MG PO/BD
6. TAB. OROFER XT PO/ BD
7. TAB. SHELCAL PO/OD
8. TAB. BioD3 PO/OD WEEKLY ONCE
9. FLUID RESTRICTION< 1.5 LIT/DAY
10. SALT RESTICITON < 2GM/DAY
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