GENERAL MEDICINE: short case
This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 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. A 58 yr old male patient labour by occupation Came to OPD on 11 th January at 4:57 pm. CHEIF COMPLAINT: Shortness of breath since 7 days Cold & cough since 6 day HISTORY OF PRESENT ILLNESS: - Patient was apparently asymptomatic 1 yr back, then he developed Shortness of breath, cough, pedal edema, decreased urine output, distended abdomen - He was taken to hospital and diagnosed to have renal failure and heart failure - He was suggested dialysis but refused and was on conservative management - SOB grade III relieved on sitting position ,increases while lying - orthopnea,chest pain, palpitations -