45 year old male with shortness of breath

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.



45 years old male pt came to opd with cheif complaints of shortness of breath (grade 2-3) since 20 days , complaints of loss of appetite since 20 days.

Patient was apparently asymptomatic 35days back, then he developed shortness of breath for which he went to a local hospital after further investigation he was diagnosed with chronic kidney disease and underwent 4 sessions of dialysis.Then referred I/V/O dialysis.

He was diagnosed with hypertension 1 month back and is on regular medication( Tab. Nicardia 10mg od) since then.

Not a known case of DM, Thyroid, TB, asthama, epilepsy.

Apetite decreased since 20 days.
He takes mixed diet.
Bowel and bladder movements are regular.
No any known allergies.

Patient consumes alcohol 1 quarter of whisky/ day daily since 12 years.Last consumption was 20 days back.

He is a known smoker.2 packs of cigarettes/ day since 20 years.

On examination, patient is C/C/C,

Pallor present


No icterus, cyanosis , clubbing , lymphadenopathy.

Edema present

Temperature 98.5*F
PR : 88bpm
RR : 18 cpm
BP : 140/90 mmhg
Spo2 : 99% at RA
GRBS : 153 mg%

CVS :- 
S1, s2 heard.

RS :- BAE +

P/A :- soft, non tender.

CNS :- no any focal deficet.



Provisional diagnosis :-

CKD on MHD since 1 month

Rx :-

1) Salt restriction less than 2.4gm/day.
2)fluid restriction less than 1 lit/day.
3)Tab.Nicardia 20mg po/bd
4)Tab.Nodosis 550 mg po/od
5)Tab.Orofer XT po/od
6)Tab.Shelcal 500mg po/od
7)Inj. Erythropoitin 4000 IU S/c once in a week.
8) Inj Iron sucrose 2amp in 100ml NS.
9) Tab Lasix 40mg po/Tid 


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