37M with Pedal oedema
Hello all this is G Jagadeesh,a fifth semester student.This E Log depicts the patient centered approach to learning.
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Date of admission:13/07/22
Chief complaint
A 37 year old male patient came to medical OPD with Chief complaints of
shortness of breath since 3 months
Bilateral pedal oedema since 3 days
orthopnoea +
History of presenting illness
patient was apparently asymptomatic 2 years back,then the patient had developed giddiness due to shock( from the death of Brother in law )for which he went to local hospital and get diagnosed with hypertension . since then the patient has started taking increasing doses of antihypertensive drugs.He is on irregular medication .
He has presented with history of Shortness of breath and Chest pain on November 2021 but it in not associated with cough and weight loss
He has studied till 9 standard and later he had discontinued because of financial problems,and he had started his own buisnessat the age of 12 years which he has runned for 3 years and later he had discontinued due to losses in buisness . Later he worked as a lorry cleaner and soon have learned driving and he had continued as lorry driver ( during this period he visisth home once ina week ) And then he used to drink alcohol frequently and had decreased food intake. In 2014 he got married Now he has 2 children after children were born he has stopped as a lorry driver, Later he has started working as daily labourer he used to do heavy work to get relieve from that he used to drink alcohol.One day in 2020 he had known that his brother - in - law has died that is his sister's husband.As this incident of Sudden death of Brother in law he had developed anxiety attack, where he went to hospital for checkup and he has known to have hypertension,the doctor have prescribed him a antihypertensive drug but for which he refused to take,And then he slowly developed bilateral pedal oedema,Shortness off breath and orthopnoea
Daily routine
He generally wakes up at 4:00 clock and goes to work by 5:30 in the morning At 6:00 clock he used to take 90 ml of alcohol and go on working,.By 8:00 clock he used to have his Breakfast generally rice and continue working In between he may, again have 90 ml of alcohol as to overcome the Stress in work and he also used to smoke, Chew tobacco frequently in between work for just to overcome the Stress and strain.By afternoon 2:00 clock he used to have lunch,He then finishes of his workby 5:30 (or) 6:00 clockin the evening but goes to home late nights drunken.Every day he used to drink alcohol frequently as a routine.Goes to bed by 9:30 in night .
Past history
He is a known case of Hypertension
N/ K/c Diabetes,TB,Asthma,seizures
Family history
NO relavent family history
personel history
Diet:Mixed type
Appetite: Normal
Bowel and Bladder movements: Normal
Sleep: Inadequate
Addictions:
Frequent alcohol consumption:180 m l per day
Frequent Smoking
Tobacco Chewing
General Examination
patient is concious coherent co - ooperative and well oriented to place and time
He is moderately built and nourished
pallor: present
No Sign of Icterus,cyanosis,clubbing,Lymphadenopathy
oedema: Bilateral pedal oedema
Systemic Examination
C V S:
SI and S2 Heard
No murmurs
Respiratory System
BAE+
per abdomen: soft and nontender
Non palpable no organomegaly.
CNS: NAD
Right Grade 3 and left grade 2 RPD changes
B/L moderate pleural effusion.
on 14/7/22
BP: 140 / 90 mm Hg
PR: 74 bpm
cVS:S I and S2+
Resp:BAE+
per abdomen:NAD
CNS:NAD
Treatment:
Inj Lasix
Inj optineuron
T Nicardia
T. Arkamine
T. Hydralazine
T. Nodosis
T. orofer
T. Ecosprin
on 15/7/22
BP: 130/80 mm Hg PR: 80 bpm
Treatment
Inj. Lasix
Inj. Optineurin
T. Nicardia
T. Nodosis
T. Orofer
T. Hydrala zine
T. Ecos prin
Fluid and Salt restriction
on 16/7/22
BP: 150/90 mm Hg
PR: 86 bpm
c VS: SI and S2 +
Resp:BAE+,clear
CNS: NAD
on 17/7/22
BP: 170/100 mm Hg
PR: 82 bpm
cvs:SI and S2 +
Resp:BAE+
CNS: NAD
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