63F with chest pain and palpitations

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Hi!! This is Vijaya ratna,9th semester medical student.This is an a 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

A 63 YEAR OLD FEMALE CAME TO GENERAL MEDICINE DEPARTMENT WITH C/O
CHEST PAIN SINCE 1 YR
PALPITATIONS SINCE 1 YR

HOPI 
PATIENT WAS APPARENTLY ASYMPTOMATIC TILL 1 YR AGO THEN SHE DEVELOPED CHEST PAIN WHICH WAS PRICKING AND BURNING TYPE A/W PALPITATIONS (INTERMITTENT) AND FEARFULNESS.
NO C/O SOB, ORTHOPNEA, PND, PEDAL EDEMA.
PATIENT HAS C/O TINGLING SENSATION & BURNING SENSATION OF B/L FEET.
C/O DRYNESS OF MOUTH, POLYDYPSIA
NO C/O POLYURIA, POLYPHAGIA.
PT HAS DECREASED URINE OUTPUT
NO C/O FEVER, COUGH, COLD, BURNING MICTURITION, VOMITINGS, LOOSE STOOLS, PAIN IN ABDOMEN.
PATIENT HAS C/O BLOATING OF ABDOMEN BUT NO C/O REGURGITATIONS, BELCHINGS.

PAST HISTORY 
H/O TRAUMA TO LT FOOT 1YR AGO FOLLOWING WHICH SHE HAD ?ANASARCA ?RENAL PROBLEM.
N/K/C/O HTN, DM, CAD, CVA, TB, ASTHMA, EPILEPSY, THYROID DISORDERS.

MENSTRUAL HISTORY 
MENOPAUSE ATTAINED 3 YRS AGO.

PERSONAL HISTORY
MIXED DIET
NORMAL APPETITE
REGULAR BOWEL AND BLADDER MOVEMENTS
ADEQUATE SLEEP
NO ADDICTIONS

ON EXAMINATION
GENERAL EXAMINATION
THE PATIENT IS CONSCIOUS, COHERENT, CO OPERATIVE.
PALLOR PRESENT
NO SIGNS OF ICTERUS,CYANOSIS,CLUBBING,PEDAL EDEMA AND LYMPHADENOPATHY 

Mid arm circumference -22cm
Triceps skin fold thickness - 9 mm
Abdominal girth - 70 cms/770mm
MAMC - 
Fvf -  2.35

VITALS
 TEMP - 97.4 F
 BP - 90/60mm/Hg
 PR - 88/MIN
 RR - 18/MIN
  
SYSTEMIC EXAMINATION 
CVS 
S1, S2 HEARD
?S3 GALLOP

RESPIRATORY SYSTEM 
B/L AIRWAY ENTRY PRESENT
NORMAL VESICULAR BREATH SOUNDS

PER ABDOMEN 
SCAPHOID SHAPED
SOFT, NON TENDER

CNS 
PATIENT  IS CONSCIOUS,COHERENT AND COOPERATIVE 
SPEECH IS NORMAL
NO SIGNS OF MENINGEAL IRRITATION
CRANIAL NERVES INTACT
MOTOR SYSTEM - POWER AND TONE NORMAL
NO SENSORY ABNORMALITIES
GCS - 15/15 

REFLEXES
                 RT          LT
BICEPS     ++         ++ 
TRICEPS    ++          ++
SUPINATOR ++        ++
KNEE            ++    ++
ANKLE      ++         ++

INVESTIGATIONS
29/10/23
HBsAg - Negative
Anti-HCV Antibodies - Non reactive COMPLETE URINE EXAMINATION (CUE) 
COLOUR - pale yellow 
APPEARANCE - Clear 
REACTION - Acidic
SP.GRAVITY - 1.010
ALBUMIN- Nil
SUGAR - ++++
BILE SALTS- Nil
BILE PIGMENTS -Nil
PUS CELLS - 3-4
EPITHELIAL CELLS- 2-3
RED BLOOD CELLS - 2-3
CRYSTALS - Nil
CAST - Nil 
AMORPHOUS DEPOSIT UREA - 28mg
CREATININE - 0.8mg/d
URIC ACID - 2.5mg/dl 
CALCIUM - 9.9mg/dl 
PHOSPHOROUS - 3.5mg/dl 
SODIUM - 137mEq/L 
POTASSIUM - 3.8mEq/L 
CHLORIDE - 102mEq/L 
LIVER FUNCTION TEST (LFT)
TOTAL BILIRUBIN - 0.5mg/dl
DIRECT BILIRUBIN - 0.22mg/dl 
SGOT (AST) - 16IU/L 
SGPT (ALT) - 15IU/L 
ALKALINE PHOSPHATE - 158 IU/L 
TOTAL PROTEINS - 7.2mg/dl 
ALBUMIN - 4.22mg/dl 
A/G RATIO - 1.42
ABG
PH - 7.40
PCO2 - 33.7
PO2 - 82.9
HCO3 - 20.9
St.HCO3 - 22.2
BEB -2.5
BEecF -3.0
O2 Sat -95.6
O2 Count -18.0

PROVISIONAL DIAGNOSIS
UNCONTROLLED DIABETES WITH ANEMIA AND ACID PEPTIC DISEASE 

TREATMENT 
TAB METFORMIN 500 MG PO BD
TAB ECOSPORIN PO HS
TAB PAN 40 MG PO BD BBF
TAB MVT PO OD 
TAB PREGABALIN 75 MG PO HS

Advice at Discharge 
TAB GLIMI M1 PO OD
TAB PAN 40 MG PO OD 5DAYS
TAB OROFER XT PO OD
TAB ECOSPORIN AV 75/10 PO HS



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