KammampatiUharollno65

 A 60 yr old male resident of daily wage labourer  by occupation came with chief complaints of lower back ache since 10 days and shortness of breath since 5 days  HISTORY OF PRESENTING ILLNESS  Pt was apparently asymptomatic 6 months back the he developed sudden onset of chest pain with high blood pressure and was diagnosed with MI and PTCA was done . Now since 5 days she developed sudden onset of chest pain and shortness of breath Chest pain is retrosternal,non radiating Shortness of breath since 5 days grade ll to grade lll , PAST HISTORY K/c/o DM since 10 years  PERSONAL HISTORY Diet  mixed Appetite Normal Sleep  adequate Bowel and bladder Regular Addictions alcoholic since 20 yrs 70ml/day and smoker since 20 yrs 2 chutta/day  GENERAL EXAMINATION Patient is conscious coherent and cooperative Moderately built and nourished No pallor, Icterus, cyanosis, generalized lymphadenopathy,edema  Mild clubbing is present Vitals  Temp Afebrile Bp 130/70 mm Hg  PR 82 bpm  RR 18 cpm  GRBS 106 mg/

 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 patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments 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. A 65 year old male resident of chityal labourer by occupation came with chief complaints of fever, cough with sputum since 15 days and chest pain from  4pm of  23/06/2023 HISTORY OF PRE