57yr old male came to casualty complaining of shortness of breath since 10days, bilateral pedal edema since 6days, generalized itching ji ji since 6days,
He was alright until 6 months ago when he noticed a small wound in his left leg. It was itchy around the site and he began to scratch the site constantly until it bled a month later. He complained of swelling and pain in his left leg as well due to which he was taken to local hospital. where he was diagnosed to have Thrombus in distal popliteal artery and told that he had Hypertension amd type 2 diabetes mellitus.
he underwent Left Popliteal artery thrombectomy and his post operative period was uneventful. He took ecospirin and vit k antagonist for 15 days.
he has been irregular with oral antiglycemics amd has not taken any medication for hypertension since then.
he was told to have Bronchial asthma 3yrs ago following an episode of difficulty in breathing and used rotahaler he is
currently he complaints of shortness of breath since 10days, bilateral pedal edema since 6days, generalized itching since 6days
personal history- he is married, has normal diet and appetite, reduced urination frequency and regular bowel habits
does not have history of any substance abuse
on examination-
pt was C/C/C
Afebrile
BP- 150/100
PR- 90
RR- 20
SPO2- 94 % at RA
CVS S1 S2+
RS- BAE+, NVBS
PA- Soft, non tender
CNS- no FND
Provisional diagnosis- chronic kidney disease with diabetic nephropathy stage 5 (7 ml per minute 1.73 m2) with metabolic acidosis a known case of diabetes since five months
plan of management
salt restrictions less than 2.4 g per day
fluid restriction less than 1 litre
per day tablet lasix 40 mg p.o t.i.d
tablet nodosis 55 mg
tab orofer XT PO OD
tab shelcal 500 mg PO OD
tab nicardia 10 mg PO OD
injection erythropoietin 4000 IU s/c weekly once
injection iron sucrose 1 ampule in hundred ml NS during dialysis
Impression from USG Doppler on 13th August 2021:
THROMBOTIC OCCLUSION OF CFA AND PROXIMAL SFA CASUING HEMODYNAMICALLY SIGNIFICANT CHANGES IN DISTAL BRANCHES > MONOPHASIC WAVE FORM IN EIA-TO R/O PROXIAML OCCLUSION
SOAP notes
AMC cubicle
subjective- patient has no fresh complaints objective- patient is c/c/c
BP- 140/80
PR 86bpm
CVS S1 S2 +
respiratory system- B/L creps present
per abdomen soft and non tender
assessment CKD with diabetic nephropathy
(stage 5)
metabolic acidosis, k/c/o DM2
PLAN
salt restriction less than 2.54 g per day
fluid restriction less than 1 litre per day
tab piptaz 4.5 gm BD
tab levocetirizine 10 mg PO HS
tablet lasix 40 mg po/did
tablet nodosis 550 MG PO bd
tab orofer XT PO OD
tab shelcal 500 mg PO OD
tab nicardia 10 mg PO bd
injection erythropoietin 4000 IU is s/c weekly once
injection iron sucrose 1 ampule in hundred ml NS during dialysis
AMC cubicle
subjective- patient has no fresh complaints objective- patient is c/c/c
BP- 140/80
PR 86bpm
CVS S1 S2 +
respiratory system- B/L creps present
per abdomen soft and non tender
assessment CKD with diabetic nephropathy
(stage 5)
metabolic acidosis, k/c/o DM2
PLAN
salt restriction less than 2.54 g per day
fluid restriction less than 1 litre per day
tab piptaz 4.5 gm BD
tab levocetirizine 10 mg PO HS
tablet lasix 40 mg po/did
tablet nodosis 550 MG PO bd
tab orofer XT PO OD
tab shelcal 500 mg PO OD
tab nicardia 10 mg PO bd
Inj. erythropoietin 4000 IU is s/c weekly once
Inj. iron sucrose 1 ampule in hundred ml NS during dialysis
Syp Aristozyme
Soap notes
AMC cubicle
subjective patient has more fresh complaints
objective
patient is C/C/C
blood pressure 150/ 90
PR 100 BPM
CVS S1 S2 present
RS BAE present
assessment CKD diabetic nephropathy stage 5 with metabolic acidosis known case of diabetes mellitus since 2 months
plan
fluid restriction less than 1 litre per day salt restriction less than 2.4 g per day
tab lasix 40 mg PO bid
tab nodosis 500 mg PO bid
tab orofer XT pure OD
tab shelcal CT 500 mg OD
tab nicardia 10 mg BD
injection piptaz 4.5 g IV BD
injection albumin 20% lv
tab levocetirizine OD HS
injection erythropoietin 4000 IU sc
AMC cubicle
SUBJECTIVE
patient has no fresh complaints
OBJECTIVE
patient is C/C/C
blood pressure 150/ 90
PR 100 BPM
CVS S1 S2 present
RS BAE present
ASSESSMENT CKD diabetic nephropathy stage 5 with metabolic acidosis known case of diabetes mellitus since 2 months
PLAN
fluid restriction less than 1 litre per day salt restriction less than 2.4 g per day
tab lasix 40 mg PO bid
tab nodosis 500 mg PO bid
tab orofer XT pure OD
tab shelcal CT 500 mg OD
tab nicardia 10 mg BD
injection piptaz 4.5 g IV BD
injection albumin 20% lv
tab levocetirizine OD HS
injection erythropoietin 4000 IU sc
calamite lotion
candid cream LA
liquid paraffin
