General medicine
37 YRS OLD MALE WITH PEDAL EDEMA
Hi, I am Durgaprasad 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
bHB sAg: Negative
HIV RAPID TEST:NON REACTIVE
b
ECG: