A 45 years old male patient with pedal edema

This is oneline e-blog to discuss our patient De-identified health data shared after taking his 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 inputs 

Chief complaints 
    A 45 year old male came to casualty with a complaint of pedal edema and SOB

History of present illness 
      A 45 year old patient who is security by occupation was apparently asymptomatic one week back then he developed pedal edema with Decreased urine output and SOB gradually progressed increased on exertion  
   First he went to private hospital and undergone dialysis four times

History of past illness 
   He was diagnosed with HTN for which he ordered renal function tests 3 years ago where his renal parameters has been damaged. He was Conservative treatment for about 3 years 
N/k/c/o Dm,Asthma, Epilepsy ,Tb
K/c/o Hypertension (3years)

Personal History 
  Status- Married
  Appetite- Normal
  Diet-Mixed
  Allergies- No
  Sleep-Adequate
  Bowel movements-Regular 
  Micturition - Normal
  Addiction- Alcohol occasionally 
     
Family History 
   Patient father has diabetes, Hypertension 

General Examination 
   Patient is conscious, coherent cooperative 
   No history of cyanosis, clubbing lymphadenopathy, pallor
   Physical status-Moderately built 
Vitals
   Temp-98.3F
    PR-78
    RR-18
    BP-130/90

Systemic Examination 
   Cvs-cardiac sound : S1,S2+
    No thrills Cardiac murmurs
Respiratory system 
   Dyspnoea-No
   Wheeze-No
    Abdomen Shape-Scaphoid 

Diagnoses 
    Chronic Renal failure 
Investigation 
   ECG

 
Treatment 
Day 1
Day 2,3
Day 4

Comments

Popular posts from this blog

A 60 year old male came with chief complaint of fever and Head ache