50 year old male with fever

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  I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis and come up with a treatment plan. 

This is the 2 nd case 

My analysis for this patient is as folows:-

Age: 50 

Sex: Male 

Occupation: Shepard 

Chief complaints:

Fever 8 days 

General weakness 6 days

Pedal edema 6 days

Analysis of each complaint in detail-

1) Pedal edema:

• Onset- Insidious
• Duration- 6 months
• Progression- Gradually Progressive 
• Type- Pitting
• Aggravated on- Walking

• Relieved on- 
• 
  
• Facial puffiness mainly periorbital edema
• Abdominal distension
• Dyspnea (Initially Grade 3 later, Grade 4 according to NYHA)
• Intermittent Palpitations
• Right sided Chest pain, non- radiating

Etiology for pedal edema:

• Rena

• Cardiac

• Hepati

History of presenting illness 

Patient was apparently as symptomatic 5 days back and developed fever chills and relieved my medication And pedal edema insidious in onset gradually progressive 

Personal history 

Diet mixed 

Sleep disturbed

Bowel and bladder regular

Addiction 90 ml 

Family history :not significant 

General examination

Parlor :no 

Icturus :no 

Lympandinopathy:no 

Clubbing :no

Kilonycia :no 

Pedal edema :Yes 

EXAMINATION OF ABDOMEN 

INSPECTION 

Shape of abdomen :scaphoid

No flank fullness

Umbilical normal 

No visible scar 

No visible pulsation 

No distentiom of abdomen 

PALPATION

temperature  : increase 

Tenderness : epigastric 

Mass in abdomen no

Oraganomegaly 

No hepatomegaly 

No splenomegaly 

PERCURTION 

No dullness 

AUSCULTATION 

Bowel sound heard 

EXAMINATION OF RESPIRATORY 

dyspnea :no

Wheeze : no 

Position of trachea: central