A 51 year male with pedal oedema and SOB

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This is 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 patients 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 comment box is welcome.

A 51 year old male came to our hospital for regular dialysis

History of present illness 

Patient was apparently asymptomatic 6 months back then he had 1 episode of seizure for which he was admitted in our hospital about 10days where he was incidentally diagnosed with hypertension.After 2 months he developed pedal oedema which increased on walking ,shortness of breath insidious in onset and gradually progressive ,grade 3 .

History of orthopnea is present 

History Paroxysmal nocturnal dyspnea present 

History of cough and cold

Decreased urine out put since 1 month,poor flow.

Burning micturation present and also complained about 

 increased frequency of urine and urgency 

No history of fever and investigation showed increased serum creatinine level .

He is undergoing dialysis since 20 days.


Past history 

Know case of Diabetes mellitus since 20 years and hypertension since 6 months 

He is on regular medication 

Not a known case asthma ,Tb , cardiovascular diseases

Personal history 

Diet -mixed

Appetite decreased 

Sleep inadequate

Bowel and bladder movements regular

Addictions: alcoholic but he stopped taking alcohol since 8 years 

He was taking tobbaco since 30 years.

Family history 

Not significant

General examination

Patient was conscious ,coherent and well oriented to time and place

Patient was moderately built and nourished 


Vitals

Temp - afebrile
RR - 18/ min
Bp - 140/ 100
PR - 82


Pallor is absent 


No icterus,cyanosis,clubbing,lymphadenopathy





Tobacco stains





Systemic examination

CVS- S1 S2 heard no murmurs

CNS- No focal neurological deficit

RS- Normal vesicular sounds heard

Provisional diagnosis

Chronic kidney disease

Investigations 












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