A long distance patient with chronic kidney disease with diabetes

 patient came to OPD for regular check up
Patient has history of constipation since 10 years for that she was took medication intermittently.And in the year of 2014 she was diagnosed with diabetes for that she is using T.Linagliptan-5 mg od. After that in the year of 2016 she had complaints of vomiting (7episodes)for which she went to hospital the she diagnosed with UTI and AKI on CKD.Again in the year of 2018, she had complaints of vomiting (10 episodes), consisting of food particles,non bilious, non blood tinged. For that she went to near by hospital and she had UTI ang High blood sugar(500mg/dl).And they given treatment for 15 days. Complaints didn't subsided.Then, they referred to higher centres(kolkata).Then, they confirmed that she had hyperkalemia and they indicated dialysis.There she undergone 1session of dialysis.And symptoms were subsided . After 6 months of recovery she had complaints of vomiting,and treated conservatively.again in the year of 2019 she complaints of vomiting,for that she went to hospital,then she diagnosed with cholelithiasis.For that she underwent gallbladder surgery(month of June).again she had a UTI infection and vomiting , after proper evaluation she had low Hb , for that they given 2 PRBC transfusion.for vomiting and UTI they managed conservatively. In the month of November they done colonoscopy and endoscopy,those were normal.again inthe year of 2020,she had a complaints of vomiting, diagnosed with small hiatus hernia and managed conservatively.Again in the month of March 2021,she had a vomiting and lose stools for that they done colonoscopy and endoscopy those were normal.
MRI was done showing cerebral ischemia small lacunar infarcts and she had hyperuemia
In april 2021 2D echo showing 
Concentric LVH dilated LA Cavity ,grade 1 Lv diastolic dysfunction 
C/o vomitings ,loose stools and generalised weakness treated conservatively.
May 2021 she had COVID and was hospitalized and was treated conservatively .


O/E
Patient c/c/c
Afebrile
Bp:90/60 mmhg
PR:68bpm
Cvs:s1s2
CNS:NAD+
Rs:BAE+
P/A: soft, non tender
Bowel sounds are heard.

Investigation:
Chest X-ray:
Provisional diagnosis:
Chronic kidney disease with diabetes mellitus type 2.

Treatment:
Tab. Linagliptin 5 mg PO/OD
Tab.ultracet po/sos.

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