A 55 yr old male,K/c/o CKD with HTN with COPD

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.

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 diagnosis and treatment plan.

A 55 yr old male patient came with C/o:
-Fever with chills since 10 days(post dialysis) 
-Came for central line replacement

HOPI:
Patient was apparently asymptomatic 3 months back, then he developed SOB,fever and cough. 
-SOB (grade-3) insidious in onset, progressive in nature 
-Fever 
-Cough(dry in nature) 
He went to the hospital with above complaints and was diagnosed with HTN(prescribed with Tab nicardia 10mg/BD, Tab arkamine), AKI on CKD( started HD)and COPD(started on Ipratropium bromide inhalers) 

No h/o TB, epilepsy, Lymphadenopathy
No h/o NSAID abuse 

Personal history:
  Alcohol abuser since 15yrs/daily 180ml
  Beedi since 15yrs/10 per day

O/E:
CVS-S1S2+
RS-BAE+
Abdomen- soft, non tender, bowel sounds heard
CNS- NAD

On general examination:

Clinical images :

palor - yes
No - clubbing, lymphadenopathy, odema, cyanosis
Temp- afebrile 
Bp-130/80mmhg
Pr-86bpm

Dialysis history:
   Total-27
   In our hospital-2
   Remaining-in miryalguda
   HD frequency-2-3times/week

Investigations done 3 months ago(in October) 
TLC-17000
Creat-9. 8
Urea-139
Bi carb-8. 2
PH-7. 32
Pus cells-(3-6) 
Albumin (+) 
K/c/o grade-2 RPD

Investigations done on 4/1/22:
Urea-200
Creat-9. 9
Uric acid -9. 6
Phosphorus-6. 5
Hb-6. 4gm/dl
PCV-19. 3
MCV-79. 1
MCH-26. 2
RBC-2. 44

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