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

A 60year old male agricultural worker by occupation resident of gudivada came to hospital with complaints of swelling on upper and lower limbs ,face since 1 week


 Hi I am, Nithin Maridi (roll no:82), 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 

* Cigarettes since 25 years

* 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.

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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