55 yr old male with bilateral pedal edema
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
55 year old male patient farmer by occupation came with chief complaints of Bilateral pitting type of edema since one and half month and Grade 2 shortness of breath since 1and half month.
HOPI:
Patient was apparently asymptomatic 1 and half month back then he had trauma to left lower limb for which he went to local hospital and used some antibiotics .Then he started developing bilateral pedal edema pitting type which was below knees and now progressed to above knees.Then he developed shortness of breath grade 2.Edema of left upper limb seen for which he went to NIMS hospital and undergone 6 sessions.There he diagnosed with HTN and he is on ARKAMIN 0.1mg BD
No h/o cough,burning micturition,orthopnea
Past history-
Known case of hypertension since 1 and hf month
Not a k/c/o diabetes,thyroid abnormalities,asthma, tuberculosis , epilepsy.
Family history - not significant
Surgical history -underwent a surgery for brain clot 15 years ago
Personal history -
Diet- mixed
Appetite -decreased
Bowel and bladder movements- regular
Sleep - inadequate
addictions-chronic alcoholic since 30 years
No h/o allergies
General examination-
Patient is conscious, coherent, coperative ,well oriented to time ,place ,person
Malnourished
O/E:
Temp- afebrile to touch
BP-160/100mmhg
Pr-17/min
Spo2-98%
Rr-20/min
Palor- present
No- icterus, cyanosis, lymphadenopathy
B/l-pedal edema present
Comments
Post a Comment