66M OPD with chest pain and SOB since 7 days, swelling in both the legs and face since 2 months

This is an online e log book to discuss our patient's deidentified health data shared after taking his/her guardian's signed informed consent. Here we discuss our individual patient's problems with collector's current best evident input.This eblog also reflects my patient centered online learning portfolio and your valuable inputs in the comment box are 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.

A 66 yr old male came to the OPD with

Chief complaints: chest pain and SOB since 7 days, swelling in the face and both the legs since 2 months.

HOPI :Patient was apparently asymptomatic 2 months ago and then developed pain in the chest 7 days ago which was insidious in onset, gradually progressive, relieved on medication associated with pain in both the knees.

SOB since 7 days which is continuous with no aggravating or relieving factors.

Swelling in both the legs and face which was slightly relieved on taking rest and aggravated on walking.

He has gastric issues since 1 year and is on medication for it, but with not relieved on taking the medication.Details of the medication are not known.

 Past history :k/c/o hypertension since 4 yrs and is on amlodipine and atenolol tablets since 4 yrs Once daily.

Personal history :

-sleep is disturbed due to discomfort

-Diet is mixed

-Reduced appetite since 7 days

-Bowel and bladder movements are regular

-no known allergies

-no addictions

Family history :nil significant

General Examination:

Conscious, coherent and cooperative 

Moderately built and nourished 

-No pallor

-No icterus

-No cyanosis

-No clubbing

-No lymphadenopathy 

-Pitting type of edema seen on both the lower limbs

Vitals:

Temperature: Afebrile

PR: 78 bpm

RR: 18 cpm

BP: 140/80 mm of Hg

Following clinical pictures have been taken with patient's consent :

Abdominal distension

Pitting type of edema

OPD Slip: