49M CCF pulmonary edema, anemia 2 weeks, Diabetes 8 years

 

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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 come up with diagnosis and treatment plan.

C/o. Shotrness of breath 1 week

Cough 1week 

Bl .pedal edema 1 week.

History of presenting illness

 

No h/0 fever vomiting diarrhoea  

cough present associated with sputum white in color, gradual in onset

Pedal oedema is pitting type and gradual in onset

Past history

Diabetes since 8 yr TAB METFORMIN500 mg 

N/k/c/0 HTN CAD ASTHMA EPILEPSY

Personal history

Occupation: He works in gold shop as a shop keeper

He drinks 1 quarter alcohol almost everyday since 15 yrs and every night when he drinks he doesn't eat any food

General examination :

Pt is c/cc

Pallor present

B/l pedal edema present 

Vitals

Bp 110/70 mmhg

Pr 82bpm

Rr 20 cpm

Cvs

Auscultation s1 s2 heard

Mid diastolic murmur present

Resp system

Bilateral air entry present

P/A soft nontender

Investigation          

29 dec

 30 dec

Xray chest

Fever charT