45 year male with Generalised Edema

Title:- 45 year male with Generalised Edema

Disclaimer:-

This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.

A 45 year male was feeling pain in body and swelling which increased gradually and after 10 days from beginning he was admitted to hospital when he was having edema in whole body, high pain and inability to stand and walk. He was also having fever.

By occupation he was a poor rikshaw puller and 4 year ago he was having frequent micturition, on visiting to doctor he was diagnosed with Diabetes Mellitus - type 2 and Hypertension. 4 years ago he also quit alcohol and smoking.

1 year ago he was having watery eyes, and got cataract surgery in left eye, vision is not good and using spectacles. 6 month ago he got cataract surgery in right eye, which inflamed, so again 2nd cataract surgery was done which again got inflamed and now 3rd cataract surgery is recommended to bring back his vision.

He is also showing signs of facial palsy due to lower motor neuron lesion.

After 5 days in treatment, edema and pain have decreased & can stand and walk now. JVP is increased. Barrel shaped chest.

Right eye corneal opacity.

left eye, visibility is low.

his daily fluid intake is regulated at 1 L.