A 65 year old male with Facial puffines 4 months; B/L Pedal edema & SOB since

 Hi, I am Nishanth Reddy Samala , 5th semester medical student. 

This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

I've 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.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

A 65 years old patient farmer and driver by occupation R/O Chilkur admitted with c/o 

facial puffiness -4 months 

B/L pedal edema &SOB-3 months

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4 months ago then had c/o facial puffiness

Since 3 months patient had c/o bilateral pedal edema pitting type extending till ankle associated with abdominal tightness ;SOB G-II dyspnea on exertion;fatigue,gen weakness

*C/o itchy skin lesions,B/L since 1 year

No c/o chest pain,fever ,cough,cold

No c/o headache & dizziness 

No c/o burning micturition & reduced urine output

No c/o loss of appetite ,insomnia 

PAST HISTORY

K/C/O  HTN-1 yr

            DM-II-2 yrs

            Asthma

N/K/C/O TB

TREATMENT HISTORY 

HTN-Since 1 yr on TELMA 40/12.5

DM-II -on ayurvedic medicine

Asthma-since 2-3 yrs

PERSONAL HISTORY

Married

Mixed diet

Normal appetite

Regular bowel

Normal micturition

Habits-

* Alcohol-regular

*smoking-stopped 10 years ago,before 20 cigarettes per day

*No drug use,betel nut ,betel leaf 

FAMILY HISTORY 

No history of HTN,GDM,Asthma,liver and kidney disorders in family

PHYSICAL EXAMINATION 

A) GENERAL

Patient is conscious,coherent and co-operative

Moderately built,Well nourished 

Well oriented to time,place 

Pallor -No

Icterus-No

Clubbing of fingers-No

Cyanosis-No

Gen Lymphadenopathy-No

Pedal edema-yes

VITALS

Temp-98.7 F

Pulse rate-80bpm

Respiratory rate-21/min

 SYSTEMIC EXAMINATION 

*CVS

S1 &S2 heard 

No cardiac murmurs

*RESPIRATORY SYSTEM

Dyspnoea

No wheeze

Central position of trachea 

Vesicular breath sounds

*Abdomen

 Shape of abdomen -obese

No tenderness and palpable mass

Liver & spleen-not palpable

Bowel sounds-present

*CNS-no neurological deficits