70 year old male with pedal edema& shortness of breath

September 13, 2022

Hello, I am Harika Madala, a 3rd sem medical student.
This is an online e-log book to discuss our patient's health data shared after taking her/his/guardian's consent. This also reflects patient centred care and online learning portfolio.

Chief complaints 

A 70 year old male, farmer by occupation, resident of Vutlapalli village presented to the OPD with chief complaints of 
1. Shortness of breath since 1 month
2. Pedal edema since 5 days

History of Present illness 

The patient was apparently asymptomatic 1 month back then he developed shortness of breath Grade IV associated with facial puffiness & pedal edema for which he was taken to a local hospital at Halya where he was investigated and Hemoglobin % was found to be 3.9 gm% He was transfused with 2 units of blood and was sent home.
The patient then developed Bilateral pedal edema(pitting type)
Easy fatiguability
No history of decreased micturition 
No history of malena
No hematuria, burning micturition 

Past history 

No DM
No HTN
No TB
No Asthma
No Epilepsy
No CAD

Personal history 

Normal appetite 
Adequate sleep 
Mixed diet 
Regular bladder and bowel movements 
Chronic alcoholic
Chrinic smoker

Family history 

Not significant 

Drug history 

Not significant 

Allergies 

Not significant 

Addictions 

Chronic alcoholic 
Chronic smoker

General examination 

The patient is conscious, coherent, cooperative and well oriented 
Pallor- Yes
No icterus
No cyanosis
No clubbing of fingers 
No lymphadenopathy 
Edema of feet- Yes(pitting type)
Vital signs 

Temperature: 98.7 F
Pulse rate: 102 beats/min
Respiration rate: 16 cycles/min
Blood Pressure: 110/70 mm Hg
SPO2: 95%

Systemic examination 

CVS

Respiratory system 

Dyspnoea- Yes
Wheezing- Yes

Investigations 

2D Echo
Hemogram
Reticulocyte Count
Complete Urine Examination 
Renal Function Test
Liver Function Test
LDH
Ultrasound
Chest X- Ray
ECG








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