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

 

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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



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