A 27 year old male with chief complaints of pedal edema.

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.


 Case:

A 27 year old male came to the opd with chief complaints of pedal edema since 1 and half year.

HOPI:

Patient was asymptomatic 1.5 years ago,he then developed pedal edema which was associated with pain and was gradual in onset.

He complained that he had chills at night.He later had vomitings  for 2 months every time after food.

Patient had no complaints of breathing difficulties.


Past history:

Patient was diagnosed with tuberculosis 2 months back.

 He has hypertension since 2 years.

No history of bronchial asthma,epilepsy and diabetes.

No history of previous surgeries.


Personal history:

                            Diet:mixed

                            Apetite:decreased

                            Sleep:normal

                            Bowel and bladder movements:normal

                            Addictions:none

Family history: none

General examination: Patient is conscious,coherent and cooperative and well oriented with time,place and person.

Pallor:+

Icterus: no

Cyanosis:no

Clubbing:no

Lymphadenopathy:no

Pedal edema:+

VITALS:

Temperature:afebrile

BP:140/90mmHg

Pulse:92/min

Respiratory rate:24/min




Systemic examination:

Respiratory system: shortness of breath,normal vesicular breath sounds heard,

CVS:S1 and S2 heard with no added murmurs

Per abdomen: not soft and tender and no organomegaly

CNS:no focal neurological defect


INVESTIGATIONS:






    






PROVISIONAL DIAGNOSIS:
CKD ON MHD

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