Case History-4

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A 48 year old man, who works as an auto driver, hailing from Chityala presented to the hospital with-

• generalized swelling of legs since 10 days.

• SOB since 7 days. ( Especially when lying down.)

Date of admission - 21/11/21.

HISTORY OF PRESENT ILLNESS

• Patient was apparently asymptomatic 2 weeks back.

• The patient usually wakes up at around 5am to 6am.

• Then after washing his face and brushing his teeth, he goes out for walking for around 30 minutes.

• After coming back, the patient resumes with his occupation of driving autos till 9pm with a lunch break at 12pm.

• The patient has his food at 9pm and goes to bed early by 10pm.

• Around 10 days back, the patient noticed swelling around his left leg while going on his morning walk.

• The patient also had a general corn inbetween his 3rd and 4th toes, and attributed the swelling to perhaps being that.

• The swelling then appeared on right leg, and then on his two hands all in the span of 3 days.

• Later the patient noticed himself suffer through bouts of fever.

• This prompted the patient to go to an RMP in Nalgonda where he was diagnosed with Pericardial Effusion (minimal) and Pleural Effusion (minimal).

• The doctor prescribed certain regimen of drugs (mentioned below) which has caused the patient to experience a bad case of shortness of breath.

• The patient also complains of orthopnea since 3 days.

• So the spouse of the patient, decided to stop administering the medication after 3 days.

• He was later brought to this current hospital where he has undergone a dialysis.

• Patient says much of his swelling and symptoms were relieved after dialysis.

PAST HISTORY

• The patient suffers from Diabetes Mellitus since 7 years.

• The patient suffers from Hypertension since 8 years.

• His Hypertension was always apparently under control with medication until his leg swelling, after which it couldn't be controlled

• 4 years back patient had a incidence of pain in the right hypochondrium - right lumbar region which had an onset on consuming food

• The patient doesn't suffer from Tuberculosis.

• The patient also doesn't suffer from asthma and epilepsy.

• They were never involved in any kinds of accidents.

• They have never undergone any surgeries.

FAMILY HISTORY

• There is no incidence of similar symptoms in any other member of his family.

• He seems to be the first person to suffer with DM in his family.

• His father has "liver problems" due to the habit of drinking.

• All the deaths in the family except his father's seem to be of natural causes.

• There are no genetic disorders or congenital deformities in his family to his knowledge.

PERSONAL HISTORY

• The patient consumes a mixed diet of vegetarian and non vegetarian food.

• Since his illness, the patient has been only taking vegetarian food.

• The patient recollects that his appetite has been very poor since last 3 days, which was relieved after his first dialysis.

• Patient is obese.

• They appear to be adequately nourished.

• Gradual decrease in micturition since the onset of illness.

• Bowel movement is constipated.

• They apparently have had the habit of smoking (unspecified quantity), drinking (unspecified amount), and pan chewing since the age of 15 years.

• They have completely ceased from all the above mentioned habits since past 4 years.

ALLERGY HISTORY

• Patient is not allergic to any known drug or food.

• There is no known allergy to dust or pollen in the patient.

DRUG HISTORY

• On equiry, the patient refused to have taken any sorts of steroids, oral diabetes drugs, diuretics, ergot derivatives, monoamine oxidase inhibitors, hormone replacement therapy or contraceptive pills — prior to coming to the hospital.

• The patient is on Insulin and Glimepiride for his DM.

• The patient also takes Olmesartan for his Hypertension.

GENERAL EXAMINATION

• The patient is concious, coherent and cooperative.

• On examination, patient's mood appears to be well.

• Their built is ectomorphic.

• The patient has oedematous face.

• No characteristic gait noted.

• There is no lymphadenopathy present

• There is presence of clubbing.

• The patient has slight icterus.

• JVP sign unable to notice because of dialysis line insertion.