37 yrs old male with pedal edema

Hi, I am Satyanarayana 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

      A 37 yrs old male Driver by  occupation resident of Neernemla yadadri district.. came to  casuality with pedal edema.

CHIEF COMPLAINTS:

              C/o pedal edema

HISTORY OF PRESENT ILLNESS:

      patient was apparently asymptomatic 4 yrs back.then he developed  swelling of both legs ..Then he went to a private hospital in Hyderabad and diagnosed with kidney disease and was on dialysis.Now patient came here for maintenance of dialysis

HISTORY OF PAST ILLNESS:

K/c/o hypertension (1 year) 

No Diabetes mellitus

PERSONAL HISTORY:

Diet: mixed

Appetite:normal

Bowels :Regular

He has a habit of taking alcohol 5 yrs back

Micturition:Abnormal

Sleep: normal

No allergies

Ni significant family history

  

GENERAL EXAMINATION:

Patient is conscious ,coherent and cooperative

No cyanosis

No icterus

Pedal edema is present

No lymphadenopathy

Ni clubbing of fingers

Systemic examination:

Pulse rate:100/min

Temperature:98 F

Respiratory rate :20 /min

PROVISIONAL DIAGNOSIS:

CKD on maintenance of Hemolytic dialysis

ULTRASOUND REPORT:

Liver, pancreas,spleen,portal vein are in normal

10*10 mm An ehoic cyst noted on interpolar region of right kidney

PLAN TO CARE:

                       Hemodialysis

SERUM LEVELS OF IRON:NORMAL RANGE

RANDOM BLOOD SUGAR:NORMAL LEVEL

Anti HCV antibodies : Negative

b

HB sAg:  Negative

HIV RAPID TEST:NON REACTIVE

ECG: