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 


VISIT PROFILE

Archive

Report Abuse




Comments

Post a Comment

Popular posts from this blog

Image
  43year old male came with the      chief complaints of  Fall due to loss of consciousness on 4/4/23 Hopi- Patient was apparently asymptomatic till yesterday morning then he had sudden loss of consciousness followed by fall on a cement brick and his clavicle fractured, he had similar complaint in the afternoon. No history of stiffness of both upper and lower limbs up rolling of eye balls , tounge bite . No history of fever, vomiting, neck stiffness, neck pain , and headache .  No history of visual disturbances.  No history of head trauma .  No history of sob , chest pain , palpitations, orthopnea .  Past history  K/c/o DM since 4years and was on medication  K/c/o HTN since 3 years Not a k/c/o asthma , tb , epilepsy and thyroid disorders  Personal h/o  Appetite- normal Diet - mixed Bowel and bladder - regular Any known Allergies- absent Addictions- alcohol- regular 180 ml /day , last intake yesterday morning.  Family ...
Read more

1801006020 - Long case

Image
24 yrs old male came to the medicine OPD with cheif complaint of unstable gait and tremors since 10 days   HISTORY OF PRESENT ILLNESSES  Patient was apparently asymptomatic 12 years ago he started drinking alcohol after  his mother passed away in a tragic accident , to alleviate that stress.  He started taking alcohol in the form of ARRACK drinking every alternative day about 1-2 glasses a day Over the next few months his consumption gradually increased to 3 glasses a  day further to 6 glasses a day.This continued upto 5 years after he started drinking .  Around 5 years later he shifted to WHISKY  due to ARRACK being banned by the government.He drink around 2 units of whisky daily before going to work and upon returning in the evening he used to feel tired thus used to drink again. In a few months time his drinking increased upto 12 units a day . patient also started chewing tobacco since the last 9 years , around 1 packet every 2-3 days He also compla...
Read more

53 year old male presented to the opd with C/O swelling of back of neck 7 years and right thigh since 5 years.

Image
  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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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  53 year old male presented to the opd with C/O swelling of back of neck 7 years and  right thigh since 5 years. HOPI : Patient was apparently asymptomatic 7  yrs back then he developed sw...
Read more