64/M with CKD

Case:
62 yr male with chief complaints
-Loss of appetite from 1 month
-SOB since 20 days
-Cough since 15 days
HOPI:
-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

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