general medicine

A 58 YR OLD MALE WITH CKD This is an online e-log platform to discuss case scenario of a patient with their guardians permission.  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 a diagnosis and treatment plan. A 58 yr old male patient Daily worker by occupation Came to OPD on 11 January 4.57pm CHEIF COMPLAINT: Patient came to OPD 7 days ago with chief complaint of    Shortness of breath since 7 days    Cold & cough since 6 days HISTORY OF PRESENT ILLNESS:  - Patient was apparently asymptomatic 1 yr back, then he developed Shortness of breath, cough, pedal edema, decreased urine output, distended abdomen - He was taken to hospital and diagnosed to have renal failure and heart failure  - He was suggested dialysis but refused and was on conservative management - SO

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.   CHIEF COMPLAINT patient came to OPD with a chief complaint of Fever since 3 days ,Lower back ache since 3 days,Generalized weakness since 3 days HISTORY  OF PRESENTING ILLNESS  Patient was apparently asymptomatic 10 days back then he developed high grade fever which was continuous ,no diurnal variation which got relieved on medication given by local RMP [some IV medication was given for 1 day and oral medication for 3 days]. Now again since 3 days he had high grade fever which was continuous