46 yr old male with complaints of SOB, Pedal edema, Anuria, Constipation.

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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.


46 Years old male came to OPD with cheif complaints of shortness of breath since 10 days.
Complaints of decreased urine output,nausea,B/L pedal edema and constipation since 10 days.

Patient was aparently asymptomatic 15 years back, then developed B/L pedal edema , shortness of breath and was brought to our hospital 1 session of HD done.Patient was diagnosed with CKD 15 years back and was treated conservatively(on and off).

Now again 10 days back he came to OPD.

Past History :-

H/O accident 10 months back where he had femur fracture,  then diagnosed with HTN and is on regular medications since then.
No H/O DM , asthama , TB , Thyroid , epilepsy.

Personal History :-

Diet : mixed
Apetite : decreased since 10 days.
Sleep : adequate.
Bowel movements : irregular
Decreased urine output
Addictions: He is a binge alcohol drinker 


General Examination:

 Patient was conscious, coherent, cooperative with place, person and time. 

Pallor present.
B/L pitting edema present till knees.


No cyanosis , icterus, clubbing , lymphadenopathy.

Temperature - 98.5 F
PR - 112/ min
RR - 18cpm
BP - 110/90 mmhg
Spo2 - 99% at RA
Grbs - 115 mg%

Systemic Examination: 

CVS :- S1 , S2 heard
RS - BAE present
P/A - soft and non tender
CNS - No focal Neurological deficet.

Investigations: 


Provisional diagnosis :-

Chronic kidney disease with Polycystic kidney disease and K/C/O HTN since 10 months.

Treatment:

1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 1 AMP IN 100ML NS IV DURING DIALYSIS

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