26 year old male with shortness of breath
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. 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. CHIEF COMPLAINTS - This is the case of a 26 year-old male who came to the OPD with chief complaints of Shortness of breath of since 10 days Bilateral pedal edema Decreased urine output since 10 days HISTORY OF PRESENT ILLNESS The patient was apparently asymptomatic 10 days back. Then he developed shortness of breath which was associated with pedal edema and decreased urine output. HISTORY OF PAST ILLNESS- K/c/o Hypertension since 10 years The patient is not a known case of Diabetes, epilepsy, asthma, CAD PERSONAL HISTORY •Mixed diet •Loss of appetite •Sleep adequ