A 70 years old male with facial Puffiness and pedal oedema
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A 70 Year old man who was a toddy tree climber,resident of chirala came to casuality 2 days back with chief complaints of pedal edema and facial puffiness from the past 15 to 20 days back
HOPI : Patient was apparently alright 3 years back ,one day he developed generalized body weakness which is intermittent in nature,so from then he is not climbing the trees
He daily wakes up at 6 am in the morning ,completes his daily routine,brushing teeth etc and drinks tea , eat breakfast by 9 am then he sits in the corridor , talks with neighbours and family members, at about 12 to 12: 30 pm he starts eating lunch and sleep for about 2 to 3 hrs in the afternoon, he wakes up by 4 : 00 pm and go for walk near his residence and come back eat dinner by 7 to 7: 30 pm.after having dinner he goes to bed.
20 days back patient and attenders noticed pedal edema and facial puffiness there is no H/O chest pain,palpitations,SOB, orthopnea
patient complains of burning micturition since 2 days
vomitings since 2 days which is insidious in onset,gradually progressive,5 episodes,non projectile, associated with nausea
it is non bilious,consist of food particles and water,not blood stained,not foul smelling
No h/o abdominal pain ,fever,cold,malena.
h/o intermittent cough aggravated by smoking from 7 days.
h/o hemorrhoid from 10 years
bleeding p/r since 1 year,h/o hard stools ,constipation ,bleed during passing stools ,minimal quantity.
past history: not a k/c/o dm,htn,asthma,epilepsy,CAD
personal History: he takes mixed diet,good appetite, bowel and bladder movements not regular
he gives h/o hard stools
sleep adequate
addictions takes alcohol regularly
90 ml per day ,smokes 20 beedis per day
Family history:
No significant family history
GENERAL PHYSICAL EXAMINATION
patient is conscious, coherent,cooperative well oriented to time place person
he is moderately built and nourished
pallor present
icterus,clubbing,cyanosis absent
edema present
no lymphadenopathy
vitals at time of admission:
TEMPERATURE: afebrile
BP:140/70 mm Hg
RR: 18 cpm
PR:76 bpm
systemic examination:
CNS : NO focal neurological deficits
CVS : visible apex impulse,no scars ,sinuses,dilated veins
apex beat is palpable
RS: shape of chest - Normal
trachea appears to be central
chest is b/l symmetrical
BAE+ Normal vesicular breath sounds present ,no adventitial sounds
P/A : abdomen appears to be normal flat shape, all quadrants move equally with respiration,umblicus is central ,no visible masses,dilated veins ,normal skin ,no scars ,sinuses,hernial orifices
no local rise of temperature,tenderness,guarding,rigidity
no organomegaly,soft and non tender
Diagnosis: severe anemia secondary to bleeding P/R
Treatment: inj iron sucrose 200 mg in 100 ml NS iv/od
syrup cremafin 30 ml /od
inj lasix 40 mg /i.v /od
inj zofer iv/Tid
monitor vitals and inform sos.
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