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A 46 YEAR OLD MALE WITH PEDAL EDEMA

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.

HISTORY OF PRESENTING ILLNESS:

A 46 year old male who is a resident of Veerlapalem, tailor by occupation came to the hospital for his maintenance dialysis.

Patient first came 14 days back with a complaint of pedal edema, pitting type, since 3 years. At first it was intermittent and aggregated on standing and when working and then since the past one month it has become continuous and unbearable 
Not associated with pain, pruritus

3 years ago he was diagnosed with hypertension for which he is taking medication and from then he says he has developed pedal edema. 

He had his first 4 sessions of dialysis of dialysis and has come back for his maintenance rounds

He developed shortness of breath 10 days back and cough and cold since 5 days back.

He has decreased appetite since one month 

PAST HISTORY:

Patient had renal stones 23 years back for which he got operated on 20 years ago.

He had diabetes since 12 years and is on treatment

He has hypertension since 3 years for which he's on treatment


PERSONAL HISTORY 

DIET - Mixed

APPETITE - Decreased since one month 

SLEEP - Adequate 

BOWEL MOVEMENTS - regular 

ADDICTIONS - was an occasional drinker until 5 years ago


FAMILY HISTORY 

His father had the same history and passed away 12 years ago



ALLERGIC HISTORY 

No known drug and food allergies. 



GENERAL EXAMINATION 

Patient is C/C/C

VITALS 

TEMP: afebrile 

BP : 140/80 

PR :90 BPM


PALLOR +

NO EVIDENCE OF ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY.


SYSTEMIC EXAMINATION 

CVS - S1, S2 heard and no murmurs 

RS - BAE + , No added sounds 

P/A : Soft , No tender, no evidence of organomegaly. 

CNS : No Focal neurological deficits. 


TIMELINE OF EVENTS:

INVESTIGATIONS

Hemogram:
Renal Function Test:
Complete urine examination:

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