A 60year old male agricultural worker by occupation resident of gudivada (Nalgonda)came to hospital with complaints of swelling on upper and lower limbs ,face since 1 week
Hi, I am Pooja Jammula , 6th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.
A 60year old male agricultural worker by occupation resident of gudivada (Nalgonda)came to hospital with complaints of swelling on upper and lower limbs ,face since 1 week
Chief complaints
Patient complaints of swelling in limbs and face since 1 week
History of presenting illness
Patient was apparently asymptomatic 1 week back
- He then developed swelling of body -upper limbs,lower limbs and face
- Pitting type, insidious onset and gradually progressive
- Complaint of chest pain,palpitation and decreased urine output
- SOB
- Ulcer over sacral region
History of past illness
Not a known case of
- Diabetes
- Hypertension
- Epilepsy
- Asthma
- Tuberculosis
No history of trauma in the past
Personal history
- Sleep:adequate
- Diet: mixed
- Bowel and bladder movements: normal
- Addictions:
- Alcohol since 25yrs regular drinker quarter
- Cigarettes since 25 years 2-3 chutta per day
- No allergies
Family history
No significant family history
General examination
- Patient was conscious coherent well and oriented to time space and person
- Patient was examined in a well ventilated room after taking his consent
- Moderately built and well nourished
- No pallor
- No icterus
- No cyanosis
- No lymphadenopathy
- No pedal oedema
- No clubbing of fingers
Vitals
- Temperature:afebrile
- Pulse:84 beats per minute
- Bp:160/80mm Hg
- Respiratory movements: 18cycles minute
SYSTEMIC EXAMINATION
Cardiovascular system
- No thrills
- No cardiac murmurs
- Cardiac sounds: S1 and S2
Respiratory system
- dyspnea absent
- No wheezing
- No Vesicular breath sounds .
- Position of trachea - central
Abdomen
- Abdomen is scaphoid
- No tenderness
- No Palpable mass
- Bowel sounds anew present
- No bruits
- No free fluids
Central nervous system
Patient was conscious and coherent well oriented to time, space and person
- Speech is normal
- Cranial nerves normal
- Motor system normal
- Sensory system normal
- Glasgow scale normal
REFLEXES
Right. Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
CEREBELLAR SIGNS
finger nose in coordination
Knee heal in coordination
GAIT
Normal.
Investigation
Heamogram,ECG,RFT,LFT,USG abdomen
Diagnosis:Heart failure with preserved ejection fraction
Grade 2 bed sores
Dilated cardiomyopathy secondary to alcohol
Acute kidney injury secondary to chronic kidney disease
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