GENERAL MEDICINE

I'm Presenting a case of 42 Year old gentleman , Farmer by occupation , resident of Nalgonda came to our casulty with 

• CHIEF COMPLAINTS 

 • Bilateral pedal oedema since 15 days 
• Fever since 7 days 
• Shortness of breath since 2 days 

HISTORY OF PRESENTING ILLNESS

• Patient was apparently asymptomatic 15  days ago , then he noticed bilateral pedal  oedema which is insidious onset , gradually progressing, pitting type (left more than right) extending upto knees ( Grade 2 ) 
• H/o Fever since 7 days , on & off low grade ,intermittent a/w Generalized weakness , not a/w chills & rigors , relieved symptomatically with medication .
• Patient had history of trauma over left lateral maleolli 10 days ago ,  followed by an ulcer & increased swelling of left lower limb .
• Patient also complained of Breathlessness since 2 days , Grade 2 progressed to Grade 3 , a/w orthopnea .

No H/o PND 
No H/o Chest pain , Palpitations 
No H/o Decreased urine output 
No H/o Burning micturation 
No H/o Sore throat 
No H/o any rash 
No H/o pain abdomen, vomiting, loose stools.

HISTORY OF PAST HISTORY 

In 2018

He accidentally got injured by an iron rod on left foot big toe which formed into an ulcer for which he took some symptomatic Rx but it didn’t  subside and the very next day the foot got swollen (?cellulitis) and he came to our hospital for which he was treated  with antibiotics and other supportive  care f/b SSG to left foot ulcer.

In 2020

He had history of fever, decreased appetite, cough for which he went to a local hospital where he was diagnosed with Tuberculosis and is on irregular medication. 

He was not k/c/o DM , HTN , Bronchial Asthma , Epilepsy CVA CAD .

PERSONAL HISTORY:

Diet – Mixed

Appetite – Decreased

Sleep – Decreased

Bladder & Bowel movements – Regular

He has been consuming alcohol 180ml daily , Chronic smoker 2 pack beedi/day and  khaini 2-3 per day for the past 20 years.

GENERAL PHYSICAL EXAMINATION 

Patient was concious coherent cooperative 

Well oriented to time place person 

Moderately build and nourished

No Pallor. 

Icterus present 

Pedal oedema present 

No cyanosis 

No clubbing 

No koilonychia 

No lymphadenopathy 

JVP - Raised 




VITALS

Temperature – Afebrile ( 98.6 F )

Pulse rate – 110 bpm , regular 

Respiratory rate – 26 cpm

BP – 110/70 mm Hg 

SPO2 – 98% on room air  

GRBS – 176 mg/dl

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

INSPECTION 

Chest is barrel shaped, bilaterally symmetrical.

Trachea appears to be central 

Movements are equal bilaterally

JVP:Raised 

Visible epigastric pulsations 

 No scars or sinuses

Apical impulse seen in 6th intercostal space lateral to midclavicular line

PALPATION

All the inspectory findings are confirmed 

Trachea is central 

Apical impulse felt at 5th intercostal space lateral to midclavicular line.

AUSCULTATION 

S1 S2 heard no murmurs 

RESPIRATORY SYSTEM 

INSPECTION

Chest is barrel shaped,

bilateral symmetrical.

Trachea is central 

Movements are equal bilaterally

Visible epigastric pulsations 

No scars or sinuses

Apical impulse not seen

PALPATION

All inspectory findings are confirmed: Trachea is central, movements equal bilaterally.

 Antero-posterior diameter of chest >Transverse diameter of chest

Apex beat felt in 6th intercostal space lateral to midclavicular line 

Vocal fremitus decreased in right IAA & ISA

PERCUSSION

Dull note heard in right IAA & ISA

Resonant note heard in all other areas bilaterally

AUSCULTATION

Bilateral air entry present – Normal vesicular breath sounds heard

Breath sounds decreased in right IAA & ISA

Vocal resonance decreased in right IAA & ISA

Expiratory wheeze heard bilaterally

PER ABDOMEN

INSPECTION 

Shape of abdomen appears to be Scaphiod 

Visible epigastric palpations 

No engorged veins sinus scars

PALPATION 

All inspectory findings conformed

Abdomen soft & Non tender

No organomegaly

PERCUSSION 

Tympanic note heard all quadrants abdomen

AUSCULTATION

Bowel sounds heard

CENTRAL NERVOUS SYSTEM

HMF - Intact 

Speech – Normal 

No Signs of Meningeal irritation 

Motor and sensory system – Normal 

Reflexes – Normal 

Cranial Nerves – Intact 

Gait – Normal

Cerebellum – Normal  

GCS Score – 15/15

PROVISIONAL DIAGNOSIS 

Heart Failure

Right pleural effusion

COPD

Left lower limb Cellulitis

FINAL DIAGNOSIS 

HFrEF secondary to ?CAD

B/L pleural effusion (R > L)

AKI

Left lower limb Cellulitis

COPD

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