general medicine elog case

50 YEAR OLD MALE  WITH COMPLAINTS OF
OF SOB SINCE 10 DAYS.
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 patient's 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 the comment box.

50 years Years old male came to OPD 
Cheif complaints:
 shortness of breath since 10 days.
Complaints of decreased urine output
Nausea,B/L pedal edema , constipation since 10 days.
HOPI:
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.

K/C/O HTN since 10 months and on regular medications.
Not a known case of DM , asthama , TB , Thyroid , epilepsy.

On examination, patient is C/C/C .
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%

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

ABG :-
RFT
SERUM ALBUMIN
USG
SEROLOGY
CBP
CUE
ECG

Provisional diagnosis :-

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

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