45 year old male with c/o pedal edema and SOB since 4 months

13/6/23
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 

 -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-cen
tred online learning portfolio and your valuable comments on comment box is welcome. 
Akhil chopde
Roll no 


45 year old male with c/o pedal edema and SOB since 4 months

Patient was apparently asymptomatic 4 months then he developed SOB and was taken to hospital and dialysis was initiated and was brought to hospital with complaints of pedal edema and SOB later after a week

No H/O Burning micturation, frothy urine, hematuria.

NO H/o chest pain,palpitations,syncopal attacks and PND and orthopnea.

No H/o cold,cough fever

K/c/o HTN since 4 months

Not a k/c/o DM,Asthama,TB,epilepsy,CVD,CAD

PERSONAL HISTORY:

Mixed diet

Normal appetite

Bowels regular

Micturation decreased 

No addictions

INSIGNIFICANT FAMILY HISTORY 



ON EXAMINATION

Patient is conscious ,coherent and cooperative and well oriented to time, place and person. 

*Pallor - present

*Icterus- absent

*Cyanosis- absent

*Clubbing- absent

*Koilonychia - absent

*Lymphadenopathy - absent

*Edema - Bilateral pedal odema present

 VITALS 


* Temperature- Afebrile
* Pulse rate-68 BPM
* Respiratory rate- 18 CPM
* Bp-  150/90 mmhg
* GRBS- 102 mg/dl



ON SYSTEMIC EXAMINATION

CVS
 S1,S2 heard
No murmurs heard

Respiratory system

BAE PRESENT


ABDOMEN:

 No tenderness, the skin is smooth and shiny, no scars or sinuses


CNS- 
* patient is conscious
* speech is normal
* no signs of meningeal irritation
* sensory and motor system normal
* gait- normal.


Investigations
















No of Hemodyalysis done till date are 
Last hemodialysis was done on 11/6/23

Surgery refferal was done i/v/o pain abdomen on 12/6/23 and was advised usg abdomen
Xray erect abdomen and review with reports 


DIAGNOSIS

 Chronic Renal Failure on MHD


TREATMENT:

Tab NIFIDIPINE 5mg PO/OD
Tab SHELCAL 500mg PO/OD
Tab BIO DS PO/weekly once


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