75 yr old with sob and cough

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

Case Discussion.

75 year old male, resident of Suryapet came to OPD with chief complaints of cough since 2 months and breathlessness since 1 month and Pedal edema since 15 days.

History of presenting illness.

Patient was apparently asymptomatic 2 years ago, later he developed SOB, pedal edema and generalised weakness for 2 weeks for which he was treated.

Later, 2 months ago, he developed cough with sputum , which is white in color, non blood stained and non foul smelling. And also SOB which gradually progressed from Grade 3 to Grade 4 ,one month ago.

He also developed facial puffiness 20 days ago along with pedal edema which is of pitting type.He has chest pain since 10 days which aggrevated with SOB.

No H/O fever with rash, hemoptysis, nausea, vomiting, constipation.

Past history:

Not a k/c/o HTN, DM, Thyroid, asthma, epilepsy, CHD.

Personal history:

Diet-mixed

Appetite-normal

Bowel and bladder movements-Regular

Sleep -adequate

Addictions-chronic smoker since 30 yrs (4 chuttas per day)

Occasionally alcoholic

GENERAL EXAMINATION :

Patient is conscious , coherent and cooperative and well oriented to time place and person, thin built.