A 46 year old male came for his maintenance dialysis
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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.
HISTORY OF PRESENTING ILLNESS:
A 46 year old male who is a resident of Veerlapalem, tailor by occupation came to the hospital for his maintenance dialysis.
Patient first came 14 days back with a complaint of pedal edema, pitting type, since 3 years. At first it was intermittent and aggregated on standing and when working and then since the past one month it has become continuous and unbearable
Not associated with pain, pruritus
3 years ago he was diagnosed with hypertension for which he is taking medication and from then he says he has developed pedal edema.
He had his first 4 sessions of dialysis of dialysis and has come back for his maintenance rounds
He developed shortness of breath 10 days back and cough and cold since 5 days back.
He has decreased appetite since one month
PAST HISTORY:
Patient had renal stones 23 years back for which he got operated on 20 years ago.
He had diabetes since 12 years and is on treatment
He has hypertension since 3 years for which he's on treatment
PERSONAL HISTORY
DIET - Mixed
APPETITE - Decreased since one month
SLEEP - Adequate
BOWEL MOVEMENTS - regular
ADDICTIONS - was an occasional drinker until 5 years ago
FAMILY HISTORY
His father had the same history and passed away 12 years ago
ALLERGIC HISTORY
No known drug and food allergies.
GENERAL EXAMINATION
Patient is C/C/C
VITALS
TEMP: afebrile
BP : 140/80
PR :90 BPM
PALLOR +
NO EVIDENCE OF ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY.
SYSTEMIC EXAMINATION
CVS - S1, S2 heard and no murmurs
RS - BAE + , No added sounds
P/A : Soft , No tender, no evidence of organomegaly.
CNS : No Focal neurological deficits.
TIMELINE OF EVENTS:
INVESTIGATIONS
Hemogram:
Complete urine examination:
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