A 32 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 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.
CASE:
A 32 year old male who is resident of Suryapet,auto driver by occupation came to the hospital for his maintenance dialysis.
Patient first experienced vertigo 1 1/2 yr ago,he went to local clinic and he came to know that he has hypertension and taken the medication for 6mns.
Then he developed bilateral pedal edema 1yr back,on investigation he came to know that his serum creatinine levels are increased .
PAST HISTORY:
*Patient had renal stones 3 years back.
*Patient is hypertensive since 1 1/2 yr for which he is on medication.
PERSONAL HISTORY:
*DIET :Mixed
*APPETITE: Decreased
*SLEEP: Inadequate
*BOWEL AND BLADDER: Irregular (decreased urine output and burning micturition)
*ADDICTIONS: Occasionally consumes alcohol
FAMILY HISTORY:
No history of any kidney releated problems
His father is hypertensive
ALLERGIC HISTORY
No known drug and food allergies
GENERAL EXAMINATION
Patient is conscious, coherent and co operative and the patient is moderately built and nourished
VITALS
*TEMPERATURE:Afebrile
*BP :130/80
*PULSE RATE :82 bpm
*RESPIRATORY RATE :18 breaths per min
*PALLOR: +
*NO EVIDENCE OF ICTERUS CLUBBING LYMPHADENOPATHY
*BILATERAL PITTING PEDAL EDEMA
SYSTEMATIC EXAMINATION
*CVS :S1 and S2 heard and no murmors
*RS : Trachea central no added sounds
*ABDOMEN : No evidence of orangomegaly
*CNS : No focal neurological deficit.
INVESTIGATIONS:
*Renal function tests:
*ECG:
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