46yr/M with pedal edema and SOB.



August 29,2022

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 box.


A 46 yr old male resident of suryapet came to hospital with chief complaints of shortness of breath grade 4 and bilateral pedal edema ( pitting type) since 6 months.

History of present illness:—

Patient was apparently assymptomatic 6 months back . Then he devoleped bilateral pedal edema till knees which is pitting type associated with facial puffiness. Then he went to the hospital . Then his baseline creatinine was 2, so managed conservatively for 4 months.Then he went to NIMS hospital , then he was initiated to hemodialysis. Total 16 sessions of hemodialysis were done previously.

Last date of hemodialysis was on 20-8-22.


Past history:—

K/C/O hypertension since 3 months and on medication 

Diabetic since 8 yrs and on medication.

CKD since 3 months 

H/O TB 10 years back — used medication.

No H/O thyroid asthma epilepsy 

Personal history:—

Diet - mixed  appetite - normal   Sleep-adequate 

Bowel and bladder movements were irregular (oliguria)

Addictions— alcoholic 8yrs ago ( now stopped taking alcohol)

Family history:- not significant 

General examination:— patient was concious coherent and cooperative and well oriented to time place and person moderately built and nourished. 

Pallor- seen 

No icterus cyanosis clubbing and lymphadenopathy 

Pedal edema is seen




Vitals:—
Temp- afebrile
Pulse rate-78bpm
Respiratory rate-20cpm
Bp 150/70 mmhg
Grbs- 154 mg%
SpO2 - 100%

Systemic examination:—
Cvs - S1 S2 heard no murmers
RS- BAE +
CNS- no focal abnormal deficits
Abdomen- soft and non tender with mild ascites.


Investigations:—








Provisional diagnosis:— CKD on MHD
plan of treatment:— hemodialysis.








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