A 46 year old male with pedal edema and shortness of breath




A 46 year old male with pedal edema and shortness of breath
August 31, 2022
31 August 2022 

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 .




A 46 yr old male resident of suryapet presented with cheif complaints Of Bilateral pedal edema since 2 months and shortness of breath since 10 days. 

HOPI





Past history-

Known case of DM since 8 years and on medication

HTN - Since 3 years and on medication

No H/o asthma epilepsy leprosy CAD

Personal history-

Diet - mixed

Appetite - normal

B&b - normal

Addictions - Alcohol since 22 yrs every alternate day. 

He has toddy, whisky and all other variants of full glass

He stopped alcohol since his 1at visit to hospital for bilateral pedal edema 3 yrs back. 

Allergies - none

Family history- 

Not sisignificant

General examination- 

Patient was conscious coherent cooperative well oriented to time place and person

Patient was examined in a well lit room and consent was taken.

Vitals -

PR-106 bpm

BP-120/60

RR-16cpm

SPo2-98%






Temp-Afebrile

Pallor - Absent

Icterus - absent

Clubbing - Absent

Cyanosis- Absent

Lymphadenooathy- absent

Edema - b/l pedal edema present (pitting type)

GRBS - 167mg/dl.
SYSTEMIC EXAMINATION-
CVS - S1, S2 heard

Resp -

CNS - NFD

Per Abdomen - soft non temder and distended abdomen

INVESTIGATIONS


PROVISIONAL DIAGNOSIS

CKD on MHD with fluid overload secondary to renal failure

Treatment -

On 29/8/2022

Fluid and salt restriction

Inj. Lasix - 40mg i/v

Inj pantop

Tab nicardia 20 mg

Tab isosorbide dinitrate

Tab carvidilol 

Tab shelcal - 500 mg B/d

Tab orofer-xt

On 30/8/2022

Fluid and salt restriction

Inj. Lasix

Inj pantop

Tab nicardia 

Tab isosorbide dinitrate

Tab Nodosis

 Tab orofer xt 

Nebulizer with budicort- 12 th hrly









Comments

Post a Comment

Popular posts from this blog

56F Abdominal pain 5 years, ileal perforation 1 year, Lump abdomen 1 month

Image
 A 56 year old female have complaints of pain abdomen since 10 days History of presenting illness-patient was apparently asymptomatic 6 months ago then she was diagnosed to had intestinal obstruction for which she got operated.Now she has complaints of left iliac fossa pain since 3 months aggregated since 10 days pricking type of pain continuous and associated with fever. No ho vomiting,diarrhoea  No h/o blood in urine,Malena ,no h/o headacge,dizziness. No h/o SOB, palpitations,chest pain. K/c/o intestinal TB 3 years ago(used ATTmedication for 1year) K/c/o hypothyroidism 10 years ago on thyronorm 50 MCG  K/c/o CAD 6 months aho N/k/c/o hypertension,diabetes,asthma,epilepsy. Treatment history Sx laparotomy for iliac perforation. Personal history: Diet :Mixed Appetite : normal Sleep: adequate  Bowel and bladder movements: regular No significant family history General Examination: Patient is conscious,coherent and cooperative Moderately built and nourished Pallor, icterus, cyanosis , clubb
Read more

65 year old female patient with altered sensorium

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 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" 65 year old female patient with altered sensorium - October 06, 2022  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
Read more

62 yr old male came to opd for dialysis

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 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 . Khushi Tulsyan Roll no. 75 A 62 yr old male farmer by occupation presented to opd for dialysis.  HISTORY OF PRESENTING ILLNESS- Patient was apparently asymptomatic 1 month back.Then he has shortness of breath while climbing Upstairs ( grade 2) Then he had decreased appetite. Then he started having shortness of breath since 10 days back even while talking . He had a decrease in his appetite since 10 days and low grade continuous fever so he visited local hospital where in routine exam
Read more