A 60 year old male with pedal oedema and SOB
This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome
Chief complaint :
A 60 years old male Resident of Nalgonda,shop keeper by occupation came to casualty with a chief complaint of pedal edema since 2 years and shortness of breath since 2 months
History of present illness:
Patient was apparently asymptomatic 2 years back then he noticed pedal edema,shortness of breath since 2 months
No H/o fever,cold,cough
History of past illness:
History of hypertension since 1 year
Diabetes since 3 months
Personal History:
Diet - Mixed
Appetite - normal
Sleep - Adequate
Micturition - Normal
Bowel and bladder movements -Regular
Addictions - No addictions
Family History:
No significant family history
Drug history:
No allergic to drugs
General Examination
Patient was conscious, coherent, cooperative well oriented to time place and person
Moderately built and well nourished
No H/o cyanosis,icterus,lymphadenopathy
Clubbing of fingers
History of pallor ,pedal edema
Vitals
Temperature- afebrile
Pulse rate - 72 bpm
Respiratory rate- 16 cpm
Blood pressure - 150 /90mmhg
Systemic Examination
Abdomen
Inspection:
Shape of the abdomen- Distended
Flanks: flanks are free
Umbilicus- central and inverted.
no visible sinuses and scars are seen.
No engorged veins
Palpation:
No local rise of temperature
No tenderness
No palpable mass
No organomegaly.
Percussion:
No Fluid thrill
No shifting dullness
Auscultation:
Bowel sounds are heard.
RESPIRATORY SYSTEM :
Chest is bilaterally symmetrical
Trachea is central
Movements with respiration are equal on both sides
Bilateral air entry present
Resonant sounds on percussion
CVS :
S1&S2 heard
No murmurs
CNS-:
Consious, coherent ,cooperative
Speech normal
No neck stiffness
Motor system normal
Sensory system normal
Able to percieve-:pain , temp.
Cranial nerves : intact
Investigations:
Diagnosis
Chronic Kidney Disease
Treatment
Tab.NODOSIS 500 mg po/BD
Tab.NICARDIA 20 mg po/ Tid
Cap.bio D3 po weekly once
Tab.SHELCAL 500 mg po/ od
Tab.REVALAMER 400 mg po/ od
