Case history-4

  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

A 46 yr old male patient presented to the opd with the chief complaint of bilateral pedal odema and shortness of breath.

History of present illness: patient was apparently normal 1 month back then he developed edema in both of his foot and also shortness of breath.the edema is of non pitting type. He was diagnosed with chronic renal failure a month back and underwent dialysis for 10 times.

Past history: patient is a known case of hypertension since 3 yrs and diabetes since12 yrs. patient underwent a surgery for the removal of renal stones 20 yrs back. 

Personal history: he follows a mixed diet. There is loss of appatite .bowel and bladder movements were normal before dialysis .after dialysis urine output decreased and there is constipation.patient consumes alcohol occasionally but stop that also 5 yrs back. No habit of smoking or Tobacco chewing.

Daily routine before his diagnosis: he wakes up around 7 in the mrng, goes for a walk, then gets freshed up and have his breakfast .then does tailoring till afternoon .in the afternoon he takes a regular south indian lunch and then goes back to work.in the night he eats dinner and goes to bed by 9 

Daily routine after diagnosis: after the diagnosis patient stoped working and continued to take the normal regular diet and he goes for walk daily twice.

Family history : patient father is also a known case of kindney failure

Drug history : no allergy to any of the known drugs. Patient uses Tab.nicardia for hypertension and Tab. Gliclazide for diabetes. 

General examination : patient is conscious ,coherrent, co operative and well oriented to his surroundings.he is well built and nourished.no pallor ,no cyanosis, no icterus, no lymphadenopathy. bilateral pedal edema is seen and is of non pitting type 

Vitals:.    Temperature:  afebrile.   Pulse rate: 76 beats / min.  Respiratory rate: 25 cycles / min.            Bp: 210/90.     Spo2: 95 

Systemic examination: 

Cvs: bilaterally symmetric chest wall .no precordial bulge .no thrills and no murmurs.

Jvp: s1 and s2 heard

Respiratory system: no dyspnoea, no wheeze

Position of trachea- central, no adventious sounds heard

CNS: patient is normal and concious .reflexs are normal.

Provisional diagnosis: chronic renal failure