A 66 YEAR OLD MALE WITH BILATERAL PEDAL EDEMA , PUFFINESS OF FACE , SOB

 End stage renal disease 

E-LOG GENERAL MEDICINE


Hi, This is Likitha, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.


A 66 YEAR OLD WITH END STAGE RENAL DISEASE


Chief complaints:

A 66 year old male hailed from suryapet presented to the OPD with chief complaints of:

Bilateral pedal edema since 3 months.                        

  SOB since 3 months.  

Puffiness of face.                                                    

    Body aches


HOPI:

Patients was apparently asymptomatic 12 years ago .

He developed chest pain and was diagnosed with IHD: S/P CABG was done.

At the same time he was diagnosed with hypertension and DM 2 for which he started taking medicine.

Then he was fine till 3 months back and started developing B/L pedal edema which is pitting type and was extended up to knees and Grade 2-3 SOB.

He went to hospital and was diagnosed with kidney disease .

Then he was planned for hemodialysis with right IJV.


1st dialysis on-23/07/22

2nd dialysis on-24/07/22

Loss of weight about 15kgs since 2 months


PAST HISTORY:

DM since 12 years.      

HTN since 12 years.                                                   

SOB


FAMILY HISTORY: 

Nil significant


PERSONAL HISTORY:

Mixed diet

Appetite-normal

Sleep-inadequate 

Bowel and bladder habits-normal

No allergies

No addictions


GENERAL EXAMINATION:


VITALS:

Patient was conscious and coherent

Well built

Temp:afebrile

Pulse rate: 72 bpm

RR: 14 cpm

BP: 110/70

Spo2: 99%


GE:

•No pallor/icterus/clubbing/cyanosis/lymphadenopathy


Course in hospital:

ECG at presentation




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