69 year old male patient with sob n bipedal edema

 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome".




A 69 year old male patient was presented to opd with a chief complaint of SOB , BILATERAL PEDAL EDEMA. 

History of present illness:

patient was apparently asymptomatic an yr ago since then he developed pedal edema, SOB and he neglected the symptoms.

6 months ago because of the  aggrevated symptoms Pt. visited local hospital with c/o SOB bipedal edema and reduced urine output and he was diagnosed with renal failure (right kidney) and was on medication past 4 months . 

Then was admitted here in the opd for dialysis.

He had 3 dialysis session s.


History of past illness:

Diabetic .

Hypertensive since 22 yrs

H/o surgery- hydrocele 4 yrs ago

No TB, asthama


Personal history:

-married

-alcoholic (occasional)

-appetite reduced

-mictutrition-reduced

-bowels - reduced

Family history:

N/h of diabetes , hypertension,asthama

Pt. Brother expired due to similar issue.

General examination:

No ascities

Non pitting type of pedal edema

Ultra sound report:


1.3*1.4cms cyst in the interpolar region of the kindney(rf)
2*1.4cms of cyst in the lower part of the kindney(lf)

Simple renal cortical cyst

Partially distended gall bladder
Pancreas - obscured.

No lymphadenopathy











Provisional diagnosis:

Diabetic nephropathy.




Comments

Post a Comment

Popular posts from this blog

45 yrs old female with hypothyroidism

Image
  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 problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input. Pedal edema Hypothyroidism 45 year old female patient  presented to OPD with a chief complaint of  :   1. Fever since 5 days .  2. Vomiting and headache since 4 days .  3. Shortness of breath since 2 days . HISTORY OF PRESENT ILLNESS :           Patient was apparently asymptomatic 5 days back . And then developed fever which is sudden in onset and gradually increasing .  Fever is not associated with chills and sweating . Fever associated is on and off since 1 month . History of vomiting since 4 days in which food particles are present as content .  History of shortness of breath since 2 days which is more during walking o
Read more

General Medicine case 1

Image
 August 16 2021. "This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome". 65 year old woman presented to the hospital with the complaints of- • vomiting • stomach ache -since 20 days HISTORY OF PRESENT ILLNESS. A 65 year old married woman and a mother of 4, who was an occasional alcoholic, who was a homemaker, was apparently asymptomatic before 20 days. Whenever she could afford, she used have alcohol. 20 days back, there was a suddenly onset of stomach pain and vomiting. The vomiting was not projectile in nature, based on the in
Read more