51 year old male patient with chief complaint of shortness of breath and decrease in urine output

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 patients 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 comment box is welcome .

A 51 year old male patient resident of nalgonda toddy seller and farmer by occupation presented to OPD with chief complaint of shortness of breath since 2 months  and decrease in urine output since 3days 

HISTORY OF PRESENT ILLNESS
Patient was asymptomatic1 year back then he complains of swelling of legs and fever consulting a local doctor ,on investigations of  examinations reported kidney problem  which was subsided on medication, 
 6 months back he again complains of swelling of legs and admitted in a hospital and doctor reported to have dialysis session till he becomes normal
He was on 2 sessions of dialysis 4months back he is on dialysis since 2months in our hospital
He has shortness of breath which was agravating while he was walking sleeping and talking since 2months 
He complains of cough since 4days and pain at upper thoracic region while coughing 

PAST HISTORY 
he is severe hypertensive 
No diabetes
2 years back he complains of pain and swelling of legs which was subsided by medication prescribed by local doctor

PERSONAL HISTORY 
mixed diet before 2 months
Occassional drinker (250 ml)
Toddy drinking daily twice 1year back

FAMILY HISTORY 
no significant family history 

GENERAL EXAMINATION 
Patient is cooperative, coherent, conscious 

pallor is present
No icterus 
No clubbing 
No cyanosis

VITALS 
temp 98.4
Bp : -160/90
Pulse rate :- 86 / min , regular, normal volume
Respiration rate :- 18 times

SYSTEMIC EXAMINATION 
CVS :- S1 AND S2 are heard 
CNS :- speech is normal , reflexes are normal 
Per Abdomen:- 
No fluid present
No palbable mass

RESPIRATORY SYSTEM
normal vescicular breath sounds present left sided crepts in ISA MSA 

INVESTIGATIONS
RFT
LFT
SERUM IRON
CBP
ECG
HBsAg-RAPID
HIV 1/2 RAPID TEST 
AntiHCV Antibodies-Rapid


Pterygium in both eyes👇

PROVISIONAL DIAGNOSIS
Chronic kidney disease on maintenance haemodialysis







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