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

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 .

K. Phani Keerthana 

Roll no 72.

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

Haemogram-


CUE-

LFT-


RFT-

ECG

2D Echo 

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




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