55 year old male

Pt is a k/c/o CKD on MHD 

previous elog

On presentation on 11/12/21

C/O Vomitings( non bilious non projectile 

Food particle as content 2-3 episodes) fever not A/W chills nd rigors ,no diurnal variations nd sob class 4 acc to NYHA classification 

Pt attenders c/o slurred speech and unresponsive to commands some times 

Pt had last dialysis on 9/12/21

O/E 

Pt conscious 

Vitals on presentation : 

BP-140/90 mmHg 

PR-82 BPM 

TEMP-100 °F 

SPO2- 93 @ room air 

CVS: S1S2 heard 

RS: Bae + ,NVBS

CNS : 

speech - slurred 

Pupils:anisocorea 

Tone : R L

      UL N Decreased

      LL N Decreased 

Reflexes :

              B T S K A P

 Right 1+ 1+ - 2+ - wd

Left 1+ 1+ 1+ - - wd 

Power: R L  

UL 4/5 2/5

LL 4/5 2/5 

Hand grip : R L 

                 80% 30 %

DIAGNOSIS:

 CKD ON MHD WITH HYPERTENSION AND DIABETES MELLITUS WITH LEFT CVA

Treatment given :

FLUID AND SALT RESTRICTION

 INJ LASIX 40MG IV/BD

TAB CINOD 10MG PO/BD
TAB NODOSIS 500MG PO/BD
TAB SHELCAL CT PO/OD
INJ ZOFER 4MG IV/SOS
INJ. ERYTHROPOIETIN 4000IU S/C ONCE WEEKLY
INJ IRON SUCROSE 1AMP IN 100ML NS IV/ WEEKLY ONCE/ DURING DIALYSIS
TAB PAN 40MG PO/OD
GRBS MONITORONG 6TH HOURLY
INJ. HAI S/C ACC TO SLIDING SCALE