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53M - CKD



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.


​A 53 year old male patient, resident of Pochampally, agricultural worker (toddy tree climber) by occupation came to the OPD with chief complaints of: 


Chief Complaints: 

Difficulty in passing urine since 10 days

Leg swelling since 5 days 

Breathlessness since 4 days 



History of Presenting Illness:  

Patient was apparently asymptomatic 10 days back, then he developed difficulty in passing urine, associated with pricking type of pain, non blood tinged, clear in appearance. 

He also developed irregular passing of stools of frequency once in 2 days after using medication.

Then he developed bilateral swelling of both lower limbs, sudden in onset and gradually progressive not associated with pain. 

Later he also developed dyspnoea, insidious in onset and gradually progressive - Grade 4 (occurred even during rest) aggravated during rest and relieved on walking. (Orthopnea+)

Patient also has cough which is productive, non blood tinged, non foul smelling. 


No history of palpitations/ burning micturition


Past History: 

Known case of Hypertension (using medication)

Known case of Diabetes (initially used medication then stopped)

N/K/C/O Epilepsy, Thyroid. 



Personal History: 

Diet Mixed 

Decreased Appetite 

Decreased Urine Output 

Decreased Bowel Moments 

Consumes Alcohol - Occasionally (2 times per week) 

Consumes Cigarettes- Pack per week



Family History: 

No similar complaints in the family. 



General Examination: 

Vitals:

BP: 160/80 mmhg 

RR: 19 cpm

HR:  68 bpm 


Pallor: Present

Icterus: Absent 

Cyanosis: Absent 

Koilonychia: Absent 

Lymphadenopathy: Absent 

Edema: Bilateral Pedal Edema 



Systemic Examination: 

Patient is conscious, coherent, co-operative 


CVS: 

S1, S2 heard


Respiratory Rate: 

Trachea Position Central 

Biphasic Stridor present 

Laboured Respiration present 


CNS: 

No neurological deficits present 


Abdomen: 

Umbilicus everted and central

No scars found




Provisional Diagnosis: 

Chronic Kidney Disease 


Treatment History: 


2-9-23

Inj. Lasix - 40 mg

Inj. Piptaz - 2.25 gm 

Tab. Nifidipine - 20 mg

Tab. Clonidine - 0.1 mg

Tab. Orofer - 1 Tab

Tab. Shelcal - 500 mg

Nab. Budecort 

CBP -30-8-23



RFT-30-8-23



Bacterial Culture - 29-8-23

CT Brain - 31-8-23
CT Brain - 31-8-23
ECG - 29-8-23
RFT - 29-8-23
CUE - 29-8-23




CBP - 29-8-23

Blood Grouping - 28-8-23
Hemogram - 28-8-23
ECG - 28-8-23
LFT - 28-8-23
RBS - 28-8-23
ABG - 28-8-23

General Examination:






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