A 32 year old male with SOB and pedal edema

 This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians 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 Elog also reflects my patient centered 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

Chief complaints::

A 38 yr old chef by occupation came to casuality with
Shortness of breath since 1 month
Pedal edema since 1month
Decreased urine output since 1month

History of present illness:::

Patient was apparently asymptomatic 1month back then he developed shortness of breath 
SHORTNESS OF BREATH which was insidious in onset gradually progressive
Grade 2-3 according to MMRC  associated with orthopnea , no paroxysmal nocturnal dyspnoea,no postural and diurnal variation ,no aggrevating or relieving factors

Pedal edema was insidious in onset gradually progressive pitting type  from ankle to shin of tibia associated with decreased urine output and facial puffiness 
H/o fever -low grade ,intermittent ,no chills and rigor,associated with burning micturition
No nausea,vomiting,loose stools
H/o cough since child hood (k/c/o bronchial asthma) cough was productive with sputum scanty whitish yellow ,no blood tinged,no foul smelling,no postural or diurnal variation 


Past History:

-K/c/o Bronchial asthma since childhood
-H/o herniotomy 7yrs back
-H/o sob after herniotomy was managed symptomatically
-H/o chest pain 1yr back and he diagnosed as bronchectasis under acute infective exacerbation with respiratory failure on o2 support  with cor pulmonale with Mod
-For which Home oxygen used at 2lt/min via nasal prongs
-H/o pulmonary Tuberculosis in childhood 
-Not a k/c/o HTN,DM,epilepsy,CAD,Thyrood disorders

Family history::
 Not significant
Personal history::
 
Diet:mixed
Sleep ::  not adequate
Appetite:: decreased
Bowel and bladder:: irregular
Addictions::no addictions
General examination::

After taking consent patient examined in a well lit room
Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Moderate built, nourishment moderate

No pallor
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
Edema present -pitting type


Vitals

Temperature::98.3f
PR-88bpm
Bp-100/70 mmhg
RR--18cpm

Local examination::

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