1601006100 long case

53 YR OLD MALE WITH B/L PEDAL EDEMA. June 12,2023.

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CASE:-

A 53 year old male who owns a hotel by occupation,came to the opd with

CHEIF COMPLAINTS:

C/O of bilateral pedal edema since 20days.

C/O of decreased appetite since 20days .

HISTORY OF PRESENT ILLNESS: patient was apparently asymptomatic 20days back then developed bilateral pedal edema pitting type extending upto the knee , insidious in onset gradually progressive since one week

~facial swelling since 7days

~yellowish discoloration of sclera since 7days

~abdominal distention since on week

~ decreased urine output since 10days not associated with burning micturition

-yellowish discoloration of urine is seen

~constipation since 15days

NO clinical complaints of shortness of breath,orthopnea,pnd,chest pain , palpitations.

No c/o of fever , vomitings,loose motion.

No c/o hematemesis,rash

No c/o melena , bleeding tendencies.

PAST HISTORY:

Not a k/c/o htn , diabetes, epilepsy, thyroid disorders.

No past surgical history .

PERSONAL HISTORY:

Marital status-married twice

Appetite-normal

Diet-non-veg

Sleep -adequate

Patient childhood :his parents had consanguineous marriage ---->patient had polio at birth ---> as growing patient had e very normal childhood ---> his father have two brothers they fought for the land finally his father got 4acres of land

First marriage:As growing he was married to person who was related to their family they had 3children ---> their marriage was not so well going now and then they used to keep fighting

Second marriage: without separation he had second marriage due to this severe family issues started --->after second marriage he started his own hotel ---then he started drinking alcohol regularly &became a total addictive .

after his first marriage he faced lot of issues then without separation -->he married again due to second marriage he faced a lot of family issues -->Meanwhile Dealing with all the financial loses

He's an alcoholic addict since 20yrs ,he's everyday consumption was about 360ml his daily routine since few months

8am -drinking

11:30am-drinking

2pm -lunch

2to5pm -sleeping

7pm -drinking.

GENERAL EXAMINATION:

Patient was conscious ,coherent , cooperative ,well built and nourished not so well oriented to time place &person at the time of presentation.

Pallor- absent

Icterus-+

Cyanosis-absent

Clubbing-absent