65 year man with Dyspnea on exertion and bilateral lower limb edema

A 65 year old from ********* presented with

 the complaints of 
Bilateral lower limb swelling since 1 month 
Dyspnea on exertion since 20 days
Black coloured stools since 20 days 


History of presenting illness

A 65 year old man, previously used to work as a farmer 6 years back, got married to his far relative and has been happily married with 3 children.

 He has been an occasional alcoholic and a beedi smoker and smokes around 3 to 4 beedis per day. He smoked last 3 months back.

25 years back, his left index finger was amputated after it got hit by a tractor.

20 years back he got into a fight with his friends following which he had a trauma to his head following which he had one episode of seizure and he was put on antiepileptics, which he used for 3 years and stopped.

Since 6 years - He has been experiencing bilateral knee joint pains so much that he stopped working. He paid a visit to our hospital and was advised for a total knee replacement. However, on further investigating him he was told that he had a heart condition because of which he cannot be operated.

He first developed pain in his right knee following which he developed left knee pain. Over the past 1 month he has even developed pain in his bilateral wrist joint, following which he developed pain in his bilateral elbow joint and shoulder joints.

2 years back - He paid a visit to a hospital for difficulty in seeing far objects for which he was prescribed spectacles, then he got even diagnosed to be a diabetic and has been on irregular medications since then 


Since 1 month - He developed bilateral lower limb swelling, first he says he developed upto his ankles which gradually progressed to his thighs over a month.

Since 20 days he also has been experiencing dyspnea on walking for short distances and he also started noticed jet black coloured stools.

He also says he has to wake up from his sleep 4 times everyday to pass urine. He says he passes urine frequently but in small quantity. 


Patient is a thin built man 
Pallor +
Bilateral pitting type of pedal edema extending upto thighs +

PR - 110bpm
BP - 90/60mmhg
RR - 18 cpm
Spo2 - 99%
GRBS - 150mg/dl
JVP raised


Systemic Examination:
On Inspection :
Apical impulse visible



Showing bilateral lower limb pitting edema extending upto thighs



Chest measurements:
Transverse - 23 cm
AP diameter - 19 cm

Inspection:


Palpation: 
Palpable apex beat
Apex beat palpated in 6th ICS 1 cm lateral to the Midclavicular line 
No palpale pulsations in aortic and Pulmonary areas
No palpable pulsations in sternoclavicular area
No left parasternal pulsations
No epigastric pulsations palpable

Auscultation:
 S1,S2 +

Respiratory system -
Bilateral airway entry +
Clear

Per Abdomen- 
Non tender
Bowel sounds +

Provisional diagnosis:
1.Anemia under evaluation 
2.Heart failure with preserved ejection fraction