A CASE

This is an online e log book to discuss our patient’s de- identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”

A 75 year old gentlemen who is a toddy tree climbers from yadagiri district came to the hospital with chief compliment of

Chief  complaint
Pedal edema since 20 days


History of presenting illness

 Patient was asymptomatic 35 years back when while climbing a Today tree during rainy day when he slipped and fell on his left leg
Near the Popliteal fossa and broke it
Conservative management was done
Even after this  he still climbee for a few years
After that he also took care of a few sheep but stopped due to his family fear

 15days back he developed pedal edema all over legs hands face 

He also developed Bouts of cough with sputum ( sputum is same type as that of early morning normal sputum)since 15 days which stopped after stopping of taking chutta

Edema of legs ,face, hands relieved on applying ointment ? And after 2 days it appears again again he applies ointment

He visited a hospital at choutupal 3 days back where he fell due to giddiness and is not able to walk since then
He is also suffering from Constipation from  many  years (2-3) relieved only on medication

2-3 days Left and right foot pain 

2-3 days Left great toe pain

Right side back of neck pain since fall due to giddiness since fall 2 days back

Past history

Eye surgery 10 years back left eye
 Daily routine

6am wake up
Take tea
10:30 breakfast ie rice
Goes out for a walk 
Comes home by 6:30-7:30
Dinner by 7:30 
Sleep

Now  also similar routine

Personal history

Diet mixed
Appetite normal
Bowel decrease since many years
              Only goes after medication
              Blood tinged
  Micturation normal
Sleep interrupted due to bouts of cough
     Addiction chutta 35-40 year 
                         Stopped 4 days back
Alcohol 90 ml whenever he wants

General examination

 PALLOR present
No ICTERUS
NO CYANOSIS
NO CLUBBING
NO KOILONYCHIA 
NO LYMPHADEONAPTHY
EDEMA present pitting type







Investigation


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