A 42 year old male,daily wage worker by occupation came with shortness of breath ,vomitings,bilateral pedal edema

Hi, I am Sravya , 5th 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. 

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-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I have 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
Bilateral pedal edema since 15 days.
Decreased appetite since 15 days.
Vomitings since 15 days.
Shortness of breath since 5 days.

HISTORY OF PRESENTING ILLNESS

 Patient was apparently asymptomatic 15 days back,then he had complaints of decreased appetite and vomitings,insidious in onset,non bilious,non projectile ,containing food particles.
He also has a history of bilateral pedal edema,pitting in type,insidious in onset,gradually progressive,not associated with any postural variations,no aggravating and relieving factors.

He has a history of shortness of breath,grade 4 insidious in onset,gradually progressive from grade 2 not associated with any postural variations,no aggravating or relieving factors.

History of watering right eye since 10 days,for which he was initially prescribed eye drops in a hospital in chotuppal.His condition has now progressed to complete vision loss and restricted eye movements in the right eye.
History of vesicles on upper part of nose on right side since 4 days which is insidious in onset and progressed to crusting and initially appeared to not be spreading and is not itching in nature.The vesicles seem to have spread to the left side of the neck which are of the same nature as that of the previous lesions.
History of bleeding from nose,which occurred following nose picking and resolved spontaneously.


No history of chest pain,palpitations
No history of fever

HISTORY OF PAST ILLNESS:
Known case of Hypertension,since 1 year,6 months.
No history of DM,CAD,TB, epilepsy 
History of Chronic Kidney Disease since 1 year,on dialysis 
History of similar complaints 1 year and 6 months,Shortness of breath and bilateral pedal edema,which was treated. Symptoms got relieved after consulting and taking medications and undergoing a session of dialysis.
He has a history of trauma accident due to falling off from a significant height,6 years ago,following high he fractured his left lower limb bones.

PERSONEL HISTORY:
Diet-Mixed
Appetite-Decreased
Sleep-Adequate
Bowel-Regular
Bladder-Regular
Addictions-Alcohol(stopped since 1 year 6 months)
                      Whiskey-90 mL everyday,since 22 years.
No known addictions

FAMILY HISTORY:
No significant family history

GENERAL EXAMINATION:
Patient is conscious, coherent, and cooperative 
Moderately built and moderately nourished.
No pallor 
No icterus 
No cyanosis 
No clubbing
No lymphadenopathy
Pitting edema seen in both lower limbs extending till the knees.

VITALS:
Temperature - Afebrile
Pulse Rate - 102 bpm
Respiratory Rate - 15cpm
Blood Pressure - 150/90mmg
Sp02 - 
GRBS - 99mg/dL

SYSTEMIC EXAMINATION 

Respiratory system:
Inspection:
No Tracheal deviation.
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.

Palpation:
No Tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- absent.
Vocal fremitus- Mammary,Infra Axillary and Infrascapular- Decreased on both sides.

Percussion:                  
Resonant note on all areas 

Auscultation:
NVBS,BAE +

Cardiovascular system:
Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation : S1 S2+

ABDOMEN
Scaphoid shaped abdomen
 No tenderness
No palpable mass
No hepatomegaly or spleenomegaly
No scars seen.

CNS
Memory -recent and remote:Intact
Speech-Normal


INVESTIGATION


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