64   years old male pt 
knonw to have   dm for the last  20  yea rts
ophthalomopathy    and he is on rejection 

before  one   and half  year   he  fiund to have   high creatinine and proteinuria 
he has   gemeralzed weakness 
  today   he came for follow uup 
he has     bilateral flank pain 
he  has lower limbs  edema 
he   has  orthopnea  
he  has itching 
he has  midl   nausea 



 medication 
calcimore
folci acid 
cadex   4 
juvista
asa  100 mg once
alloril   100 mg once 


today   he came  for follow up 
creatinien  6.4



plan 
add  deflkazacort 
add    biosolve 
alfacal 
calcium 
