71 yrs old male with b/l pedal edema

 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

Cheif complaints 

 

 Bilateral pedal oedema since 4 days

 SOB - since 4 days  ( grade 2) 

 Reduced urine output - since 4 days 


History of present illness 


Patient was apparently asymptomatic 2 years ago then developed loin pain , pedal edema and facial puffiness,  after then he went to hospital and diagnosed as renal disease which progressed even after medication .

After that due to failing of kidney he had undergone for dialysis - 1 yr back. 

Now he has pedal edema which is of pitting type , sob grade 2 and constipation since 4 days. 


Daily Routine : 


Wakes up at 5am and goes to field

Breakfast - 8am 

Returns to work at 9am.

lunch - 12:00pm

6pm - home

8pm - dinner

9 pm - sleep 



past history 

history of diabetes mellitus, hypertension - since 25yrs .

no history of TB , epilepsy , thyroid disorder .

history of dialysis . 


PERSONAL HISTORY: 


Diet - mixed

Appetite- normal

Sleep - normal 

Bowel - irregular (constipation) since 4 days 

Bladder - oliguria since 4days , burning micturition.

Allergies- none

Addictions-

 cigarette smoking since 40yrs

  Drinks toddy - since 40 yrs . 




FAMILY HISTORY:


Not significant 




GENERAL EXAMINATION: 


Patient is conscious, coherent and co-operative.

Moderately built and nourished

Examined in a well lit room.



Pallor - present 

Icterus - No

Cyanosis -no 

Klubbing - no

Lymphadenopathy - no

B/l pedal edema - present - bilateral pitting type






              

Vitals : 


Temperature- afebrile


Respiratory rate - 16cpm


Pulse rate - 78 bpm


BP - 120/80 mm Hg.




SYSTEMIC EXAMINATION: 

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination: 

INSPECTION : 

Shape of abdomen- scaphoid

No tender

no palpable mass

hernial orifices - normal 

Umblicus - normal 

Movements of abdominal wall - moves with respiration

No scars, sinuses, distended veins, striae.

PALPATION : 

Local rise of temperature present.

Tenderness present - not present 

Rigidity absent 

Fluid thrill negative

Liver not palpable 

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 


CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

Gait: normal


INVESTIGATIONS: 

Serology:







PROVISIONAL DIAGNOSIS:


Chronic kidney disease on maintenance hemodialysis 


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