70Y M with CHEST PAIN

 2023 DEC 


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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.

Patient and his/her attenders have been informed and their consent has been taken.

70 Y M WITH CHEST PAIN

HOPI :

Patient came with complaints of chest pain since 1 hour which is insidious in onset, gradually progressive, radiating to back. 

Associated with  SOB grade 3, palpitations, orthopnea

No complaints of vomitting, sweating, giddiness, decreased urine output. 

PAST HISTORY

Not a k/c/o DM, HTN, ASTHMA, TB, Epilepsy, CAD, CVA

Right leg fracture  10 years back

PERSONAL HISTORY

Diet - Mixed

Appetite - Normal

Sleep - Disturbed

Bowel and bladder movements -regular

No known allergies 

Addictions Alcoholic occasional  toddy 90ml 

Smoker stopped 10 years ago


GENERAL EXAMINATION

Patient is conscious, coherent, cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy






 Temp: 98.6°F

PR- 68bpm    

RR- 17cpm

BP- 150/80 mmHg

Spo2 -98%at RA

Grbs- 256mg/dl


SYSTEMIC EXAMINATION

CVS S1 S2heard no murmurs

RS -  BAE, NVBS heard, Crepts over bilateral IAA, ISA

P/A - Soft, non tender

CNS- NFND

INVESTIGATION

Hb- 12.8, Tlc- 8800. Plt- 3.32

Cue sugars +

LFT:

TB- 0.70 DB- 0.19. AST/ALT - 12/9

ALP-173. TP- 7.5, Alb- 4.5

RFT

U-2e. S.Cr- 0.9 Na+137 K+ 3.2 Cl- 98 Ca 10.0

Rbs 257

Troponin I 9.4pg/ml.



Usg Abdomen : Grade 1 Fatty liver, Grade 1 RPD changes

2D echo



DIAGNOSIS

Chest Pain under evaluation

? Angina With COPD

Heart Failure with Preserved Ejection Fraction (53%) 

TREATMENT

Inj Tramadol

Inj Pan

Inj Lasix

Neb with Budecort and Duolin

Syp Potclor 10ml

Fluid restriction


Day 2



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