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

 


October 17, 2023

 Hi I am, Madhuri palsa  5 th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.



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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