65year old female came to opd with known case of 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

Chief complaints:pt came to OPD with known case of CKD for MHD

HOPI:pt was apparently asymptomatic 3months back then she had history of pedal edema insidious in onset and gradually in progression upto knee

And history of shortness of breath since 3months insidious in onset and gradually in progression which is grade2, associated with loss of appetite and decreased urine output she went to hospital and she found to have increased creatinine level and bilateral kidney failure 

Past history: history of HTN and DM

and no history of Tb,asthama, thyroid abnormality,

Personal history:

Diet: mixed

Appetite:normal

Sleep: adequate

Bladder and bowel movement:regular

History of taking alcohol and bedi

General examination:

Pt is conscious, coherent, cooperative well orientated with time,place ,person

Moderately built and moderately nourished

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Edema: absent 

VITALS:

TEMP: Afebrile

RR:18cpm

BP:110/80

PR:65bpm

Spo2:98

SYSTEMIC EXAMINATION:

CVS:S1 and S2 sounds heard

RS:NVBS +

CNS:no focal neurological deficit

Abdomen:

Inspection:scaphoid abdomen,no engorged veins

On Palpation:no tenderness seen

On Auscultation:bowel movements heard

Investigation:

1)CBP:

2CUE:

3LFT:

4RFT

ECG:-

USG

HIV

Serum Iron 

Provisional diagnosis:

This is case of patient involving renal system probably chronic kidney disease secondary to Hypertension and Diabetes mellitus.