A 55 year old male with SOB and pedal oedema

Hello, I am Harshitha Shalini , a 5th semester medical student.  This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

A 55 year  old male patient resident of  madhavagudem came to OPD with

 CHIEF COMPLAINTS -

-SOB since 15 days

-pedal edema since 1 week

HOPI:

Patient was apparently asymptomatic 15days back then he developed SOB (grade 1and2) that was  insidious in onset, gradually progressive 

C/o pedal edema since 5 years and aggravated since  last 15 days it is a pitting type

C/o decreased urine output since 1week

No C/O chest pain, palpitations, orthopnea, PND.
No H/O fever, burning micturition, loose stools, vomiting. 
No C/O pain abdomen.

PAST HISTORY:

/K/C/O HTN,DM epilepsy ,  TB ,thyroid disorder

K/C/O CKD diagnosed 1month back

PERSONAL HISTORY: 

Diet - Mixed
Appatite - Normal
Sleep - Reduced
Bowel and Bladder - Reduced urination, normal bowel.
Allergy - None
Addictions 
- Alcohol - about 90ml per day since his teenage.
- Beedi - 1 packet per day since his teenage.

FAMILY HISTORY: 

 No significant family history

GENERAL EXAMINATION:

The patient is conscious,coherent and cooperative; well oriented to time,place and person.

He is moderately build and well nourished.

Pallor - present 

Icterus- present 

Clubbing-absent

Cyanosis-absent

Lymphadenopathy-absent

Edema - B/L pitting type present, extending upto the knee.


Vitals: 

Temperature -98.6F
Pulse rate - 94/ minute 
Respiratory rate - 20/minute
Blood pressure (left arm) - 100/60 mm of Hg
GRBS - 105 mg/dl

Systemic Examination 
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System 
 no dyspnea 
No wheezing
central trachea
vesicular breath sounds
Abdomen
Scaphoid shaped abdomen 
 No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal speech

INVESTIGATIONS :
ECG

2D echo
USG

PROVISIONAL DIAGNOSIS:
Chronic kidney disease

Treatment:
Inj. Lasix 40mg  IV 
Tab. Nodosis 500mg
Tab. Orofer
Tab. Calcitriol

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