52 year old with chronic renal failure

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

52 year old female came to OPD with chief complaints 
1)SOB since 3 days
2)loss of appetite since 3 days
3)pedal edema on & off since 3 months
4) decreased urine output since 3 months

HOPI:she was apparently asymptomatic 3 months back then she developed sob since 3 days progressed to grade 4 since 1 day ,loss of appetite since 3 days

15 days ago c/o low grade fever subsided in 3 days ,not associated with chillz
 
On 16/11/21 ,she went to hospital with complaints of pain in abdomen,generalised body pains, backache
They did USG of abdomen - Bilateral small kidneys.

In March 2022  ,she went to hospital with complaints of sob and pedal edema and took medication 
Outside reports:
Hb-6.5mg/dl
TLC-8200
RBC-2.6
Serum creatinine-10
Rbs-85
USG of abdomen-coarse Hepatic parenchymal echotexture
-Bilateral grade 2-3 RPD Changes
-Simple left renal cortical cyst

Past History:
K/c/o HTN diagnosed by RMP doctor is on irregular medication

Personal History:
Farmer by occupation
Diet- mixed
Appetite lost
Bowel & Bladder movements- Regular
Addictions - occasionally drinks toddy

On examination 
She is conscious, coherent, cooperative
Vitals at admission
Temp-98.6F
PR-113bpm
RR-40cpm
Bp-150/80mmhg
Spo2-98@ RA
 
pallor present
No cyanosis/clubbing/lymphadenopathy

CVS- S1,S2 heard,no murmurs
RS- BAE Present,
CNS- NAD
P/A- soft,BS +

4/5/22
Provisional diagnosis: chronic renal failure
Treatment
1)Inj.Piptaz 2.25gm IV/TID
2)Inj lasix 40mg IV/BD
3)TAB Nodosis 500mg p/o TID
4)TAB shelcal P/O OD
5)Cap BIO-D3 PO/OD
6)Tab Orofer XT PO/OD
7)INJ Erythropoietin 5000 IU S/C once weekly
8)INJ Iron sucrose 1 ampoule + 100ml NS IV once weekly

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