77 year old male with SOB

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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

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CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS

Case discussion:

A 72 year old male patient fruit vendor by occupation was brought to the OPD with a chief complaint of shortness of breath (SOB) since the past two months.

History of presenting illness:

Patient was apparently asymptomatic 7 years back, later he developed chest pain and was taken to a hospital (no records of that visit).

2 years age there was a complaint of bilateral knee pain and is on medication for it ( unknown medication). He was also diagnosed with hypertension to which he took medicatIon for 4-5 days and stopped. At present he uses an unknown medication occasionally for HTN.

2 months ago he developed SOB that was insideous in onset and progressive from grade 2 to grade 3 ( increase in grade with walking)( grade 2 to grade3). Symptoms increased in severity since the past week, associated with wheezing. Not associated with cold, cough, chest pain, palpitations, fever. There is no postural or diurnal variation. There is no history of paroxysmal nocturnal dyspnea.

Past history:

Patient is a known case of HTN since the past 2 years.

There is no H/O diabetes, asthma, epilepsy or tuberculosis.

Family history: Not associated

Personal history:

Diet: mixed

Appetite: normal

Bowel movements: reduced

Bladder: increased frequency

Sleep: adequate

Addictions: none

Allergies: none known as of now