55 yr old male with abdominal distension

September 13, 2022

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CASE:-

55 year old male complaints of abdominal distension and b/l pedal edema (pitting type) , shortness of breath and scrotal swelling.

CHIEF COMPLAINTS:-

Patient complaints of

•Abdominal distension

•B/l pedal edema

•Shortness of breath

•scrotal swelling

Since 25 days

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 6 years ago, then he had swellings over chest for which he went to hospital and was diagnosed as diabetic and was on medication since then.

•2 years ago when he went for routine checkup he was diagnosed as hypertensive and was on medication .

•6 months back patient's speech was reduced for which he went to a local hospital where he was found to have low GRBS (27 mg/d) and he

also had jaundice and was advised to stop consuming alcohol.

•25days back he developed scrotal swelling, pedal edema, abdominal distension which was insidious in onset and gradually progressive, he also exhibited shortness of breath, for which he went to an RMP and was referred to KIMS, Narketpally.

PAST HISTORY:-

*H/O DM since 6 years and used tab.glibenclamide 5mg+ metformin 500mg, stopped taking medication since 6 months *H/O HTN since 2 years and taken Tab. Telma 40mg.

FAMILY HISTORY:- Insignificant.

PERSONAL HISTORY:-

•Diet:- mixed

•Appetite:- normal

•Sleep:- adequate 8 hrs per day

•Bowel and bladder :- regular

•Addictions:- ☆chronic alcoholic since 20years

-360 ml per day, stopped drinking since 1 month.

☆ Chronic smoker since 30 years - 2 packs per day .

•Occupational history:-hotel owner

GENERAL EXAMINATION:-

Patient is conscious, coherent and cooperative well oriented to time, place and person.