A 40 yr old female with chronic renal failure?

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"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"

40 yr old female came for follow up .No fresh complaints.

HOPI:
Pt was apparently asymptomatic 1 mnth back then pt has developed lack of appetite, generalized weakness and difficulty in breathing and decreased urine output. She went to hsptl outside and diagnosed as Renal disease and on managed outside hsptl.
Pt came here for further treatment.
Past history:
K/c/o T2 DM since 10 yrs.
K/c/o HTN since 1 yr.

Diagnosis:
CRF
?Diabetic nephropathy
With DM with HTN

Treatment:
1.Fluid restriction <2 L /day
Salt restriction <2gm/day
2.Inj.Lasix 40 mg IV/BD
3.Inj.HAI s/c TID
Check GRBS 
4. Tab.MET XL 50 mg PO/OD
5.Tab.Ecosprin 10 Mg PO/OD
6.Neb.with DUOLIN 8TH HRLY
BUDECORT 12 HRLY
7.TAB.ZYTANIX 5 MG /PO/OD
8.TAB.OROFER XT /PO/OD
9.TAB.NICARDIN 10 MG /PO/BD
10.MONITOR VITALS

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