66 years with shortness of breath

March 14, 2023

This is 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 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

M Kalpana

Roll no -92

Case history-

66 years old male ,who is chronic smoker came with the complaints of

Shortness of breath since 4years

Cough since 3years

History of illness-

Patient was apparently asymptomatic 4 years ago then he developed shortness of breath, insidious in onset,gradually progressive ,progressed from grade 1 to 2( MMRC) ,shortness of breath is more after smoking

no orthopnea,no PND, no pedal edema

No h/o seasonal and diurnal variations

Cough since 3years,dry cough ,more after smoking , no seasonal and diurnal variation

No h/o fever,chest pain,vomitings, Palpitations

Past history-

Not a known case of HTN,DM, asthma,,CAD, thyroid and seizure disorders

Personal history-

Occupation-agriculture labourer

Appetite -normal

Bowels- regular

Micturition-normal

No allergies