General medicine

I'm Maimuna Fathima,3rd year BDS student 
February 20,2023

This is an E-log to discuss case scenario of a patient with their guardian's help.
I have been given this case to solve in an attempt to understand topic of patient,clinical data analysis to develop my competency in reading and comprehending clinical data including history,clinical findings,investigation and come up with diagnosis and treatment plan.

A 56 year old male resident of Jununthala is a farmer,presented to the OPD with the chief complaints of swelling in upper and lower limbs since 15 days.
HOPI:
Patient was apparently asymptomatic 15 days ago then he had street food after which he noticed puffiness in the face and limbs.The swelling was bilateral in both upper limbs and lower limbs,insidious in onset,gradually progressive with no aggrevating and relieving factors.
Associated with nausea,indigestion.
Past history:
Known case of hypertension since 8 years(on med),Diabetes mellitus since 8 years.
History of koch's 10 years ago(ATT taken).
Family history:Not significant.
Personal history:
Diet:Mixed
Appetite:Decreased 
Bowel bladder:Not regular 
Sleep:Adequate 
Addictions:Alcoholic,tobacco,gutka 

General examintion:
Patient is conscious,coherent, cooperative,oriented to time place and person.
Vitals:
Afebrile
Pulse rate:80bpm
BP:130/70mmHg
RR:18/min
Pallor:Absent 
Icterus:Absent 
Clubbing:Absent 
Cynosis:Absent 
Lymphadenopathy:Absent 
Edema of foot present. 

Systemic examination:
CVS:S1,S2 heard 
Respiratory system:
Dyspnoea present
Trachea central
Abdomen:Soft,non tender 
Bowel sounds heard.

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