General Medicine - 19

A 70 YEAR OLD MALE CAME TO OPD WITH BILATERAL PEDAL EDEMA

This is an online E log book by D.SRI SNEHITHA 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've 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 a diagnosis and treatment plan. 

CHIEF COMPLAINTS:

A 70 year old male came with the chief complaints of: 
- swelling of both feet since 20 days

HISTORY OF PRESENT ILLNESS: 

The patient was apparently asymptomatic 20 days back. He then complained of bilateral pedal edema , sudden in onset, gradually progessive , with no pain
No aggrevating and relieving factors.
No history of fever, burning micturition


PAST HISTORY:
  Previous history of hypertension 1 month back and on regular medication with AMLODIPINE 5mg

Previous history is anuria of 3 months and treated accordingly 2 years back
Previous history of appendix sugery 

Not a known case of asthma , diabetes mellitus, tuberculosis, epilepsy, coronary artery disease, cerebrovascular accidents.
No similar complaints in the past


PERSONAL HISTORY:


Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: decreased
Habits:alcoholic (90 ml per day) 
Sleep: inadequate 
No history of allergy.

Family history:
Insignificant

Drug history: AMLODIPINE since 1 month

GENERAL EXAMINATION: 

The patient is examined in a week lit and well ventilated room
Moderately built and moderately nourished
No pallor 
No icterus 
No cyanosis
No clubbing
No lymphadenopathy
Pedal edema present


VITALS:

Temperature: febrile

Pulse: 73 beats per minute, irregular

Respiratory rate: 18 cycles per minute

Blood pressure: 120/80 mm of Hg

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