46 year old male patient presented to opd with chief complaint of shortness of breath and bipedal edema

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 46 year old patient from miryalguda tailor by occupation  presented to OPD with chief complaint of bipedal edema since 2 months and shortness of breath since 2months

HISTORY OF PRESNT ILLNESS

patient was asymptomatic 3 years back and later developed edema in legs and it was subsided because of medication prescribed by local doctor

Before 2 months from present he again developed edema in legs and visited local doctor on investigations of urine examination doctor prescribed to take dialysis 
From 2 months he is on dialysis in our dialysis ward and he presented 2 times to opd for dialysis in our hospital
He said he was suffering with fever and chills during dialysis
No appetite 
Thirsty feeling 

PAST HISTORY
He is a known case of hypertension since 3years 
Diabetes since 10 years
He is having shortness of breath during his sleep at night
He had lasik surgery to his both eyes which was failed and he is now having blurred vision 

FAMILY HISTORY
His father died due to severe kidney problem

PERSONAL HISTORY
Mixed diet before 2months 
Present vegeterian diet

TREATMENT HISTORY

GENERAL EXAMINATION 
patient is conscious coherent coperative

No Pallor
No Cynosis
No Icterus
No Clubbing

Vitals

Temp :- 98.4
Bp:- 130/90
Pulse :- 83 beats/min
Respiratory rate:-  20 times 

SYSTEMIC EXAMINATION 
CVS  S1 AND S2 SOUNDS heard 
CNS  CONSCIOUS,  SPEECH NORMAL 

RESPIRATORY  

PER ABDOMEN 
no fluid present
No palpable mass
Liver not palpable
Spleen not palpable

INVESTEGATIONS



Click on the link below👇 to watch video
SERUM IRON
BLOOD GROUP
HBsAg-RAPID
LIVER FUNCTION TEST
RFT
HIV 1/2 RAPID TEST
HEMOGRAM

PROVISIONAL DIAGNOSIS
Chronic kidney disease on maintenance haemodialysis and diabetic nephropathy




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