60 year old male patient complaint of pedal edema and shortness of breath

Final exam Short case



60 Years old Male patient with a cheif complaint of pedal edema, shortness of breath

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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

Chief complaints :
A 60 years old male Patient complaints of pedal edema  since 2 years and shortness of breath since 2 months

History of present illness:
Patient was apparently asymptomatic 2 years back the he noticed  pedal edema extended upto knee ,shortness of breath since 2 months
No H/o fever,cold,cough

History of past illness:
History of hypertension since 1 year
Diabetes since 3 months 

Personal History:
Diet - Mixed
Appetite - normal
Sleep - Adequate 
Micturition  - Normal
Bowel and bladder movements  -Regular
Addictions - No addictions 

Family History: 
No significant family history
Drug history: 
No allergic to drugs
General Examination 
Patient was conscious, coherent, cooperative  well oriented to time place and person 
Moderately built and well nourished
No H/o cyanosis,icterus,lymphadenopathy 
Clubbing of fingers 
Vitals 
Temperature- afebrile
Pulse rate - 72 bpm
Respiratory rate- 16 cpm
Blood pressure - 150 /90mmhg

Systemic Examination

Abdomen
Inspection
Shape of the abdomen- Distended 
Flanks: flanks are free
Umbilicus- central and inverted.
no visible sinuses and scars are seen.
No engorged veins 

Palpation:
No local rise of temperature 
No tenderness 
No palpable mass
No organomegaly.

Percussion:
No Fluid thrill
No shifting dullness

Auscultation:
Bowel sounds are heard.

RESPIRATORY SYSTEM :
Inspection 
Chest is bilaterally symmetrical
Trachea is central
Movements with respiration are equal on both sides
Bilateral air entry present
Resonant sounds on percussion
Palpation 
No local rise in temperature
No tenderness

CVS :
S1&S2 heard
No murmurs

CNS-:
  Consious, coherent ,cooperative 
   Speech normal
   No neck stiffness
   Motor system normal
   Sensory system normal
   Able to percieve-:pain , temp.
   Cranial nerves : intact


INVESTIGATIONS 

USG

ECG

Diagnosis 
Chronic kidney disease 

Treatment 
Tab.NODOSIS 500 mg po/BD
Tab.NICARDIA 20 mg po/ Tid
Cap.bio D3 po weekly once
Tab.SHELCAL 500 mg po/ od
Tab.REVALAMER 400 mg po/ od

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