66 years old man -Swelling of both lower limbs

General Medicine.
19th August, 2023
 Case scenario.
      Hi I Mogili Julia Spencer 3rd bds student, this is an online e log book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio.
  
Case history:  
Patient details: 
    A 66 yr old male, occupation by farmer, a resident of cherlapally, presented with chief complaints of
            Complains of swelling of both the lower limbs till knee since 1 month.

History of present illness: 
    Patient was apparently asymptomatic till 1 month ago, then developed swelling of both lower limbs which is pitting type . 
  Also associated with slurring of speech.
  Not associated with facial puffiness.
   
History of past illness:
    Known complaint of hypertension since 30yrs
And on medication.
 Diabetes: no
 Asthma: no
 Epilepsy: no
 Tuberculosis: no
 CVA: hemeparasis which is resolved 6 yrs ago.

Personal History: 
Occupation: farmer 
Appetite: normal
Diet : nixed
Bowel : regular
Micturition : normal
No known allergies
 Addiction: alcohol consumption regularly

Family history: not significant

General examination: 
Built: normal
Patient is coherent cooperative and conscious
Pallor: no
Icterus: no
Clubbing: no
Cyanosis: no
Lymphadenopathy: no
Edema: present since a month 
Malnutrition: no
Dehydration: no

Vitals: 
Temperature: 98F
Pulse rate : 84/ min
Respiratory rate: 21/min
BP : 140/80 mmHg

Systemic Examination: 
CVS: no cardiac murmurs 

Respiratory: trachea - central
         No dyspnea, no wheeze 

Abdomen: distended
          No tenderness 
          Spleen and liver are not palpable

CNS: conscious
       Slurred speech.

Provisional Diagnosis: 
    Ascites and renal failure.

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