70 year old male with bilateral lower limb swelling and facial puffiness

September 15, 2022

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog 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 diagnosis and treatment plan.

A 70 yr old male patient toddy climber by occupation and resident of Nalgonda presented to opd with chief complaints of

Swelling in both legs since 15-20 days

Facial puffiness since 15-20 days.

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 3 yrs back. Then he complained of generalized weakness while doing his work which apprently made him discontinue his work.

From past 1 yr he is having constipation 1 episode every 3 -4 days which is occasinally associated with blood which was in minimal quantity. So he visited local doctor with chief complaint of constipation (and he didn't tell about loss of blood in stools back then) . For which the local doctor gave him some medication for constipation which was then temporarily relieved he would have urgency to defecate but would only pass flatus.

There is a history of cough since 4-5 months associated with sputum non blood stained. Excess sputum secretion is present.

He is known to be having intermittent lower leg swelling which would then reduce by itself.

But 20 days back he noticed lower limb swelling upto knees which is pitting type and facial puffiness insidious in onset gradually progressive not associated with chest pain or difficulty in breathing and for which he visited a local rmp for which he was given a tablets and then the edema was subsided temporarily so he went to some other far hospital yesterday where after having his breakfast he alone went to the hospital where he because of travelling and heat he was dizzy and vomited which had food as it's contents non foul smelling non bilious. And after a series of test there he was found to be anemic with hameglobin of 3mg/dl and was referred to higher institution so he came to our opd with cheif complaints of bilater lower limb swelling, facial puffiness and anemia.

Past History:

Patient is a not a known case of Hypertension, DM,TB,Epilepsy,CAD.

Personal History:

Sleep adequate,

Appetite normal

Diet mixed

Bowel - irregular,

Bladder regular

Addiction: regular alcoholic , 90ml whisky,Smoking -20 beedis per day since 30 years and stopped one week

Family History:

No significant.

General examination: