GENERAL MEDICINE
15/09/2023 68 year male with SOB,Chest pain, Giddiness
Hi, I am Pindi Gayatri, 5th sem medical student. This is an 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 patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatsoever.
Chief Complaint:
68 year old male resident of Narketpally came to OPD with chief complaints of
-SOB since 2 months
-Chest pain since 2 months
-giddiness since 2 months
History of Present Illness:
Patient was apparently asymptomatic 2 years ago then he developed giddiness 1-episode/day for which he got CT brain done at outside hospital was told that he had an infract since then he was on medication for the same.
2 month ago patient developed chest pain was taken to outside hospital and was on medication since then.
Now patient is getting exertional dyspnoea with chest pain which subsides with rest
No h/o orthopnea,PND,
Pedal edema (onn and off)
No h/o of fever, nausea and vomiting,loose stools, burning micturation, headache
Daily Routine:
Before she got sick, she used to wake up at 5am every morning, cook for her and her husband, take a bath at 6.30am, wash clothes and dishes by 8am, eat breakfast of rice and curry and leave for work by 8.30am. She is a daily wage laborer by occupation and she used to pack lunch which was the same rice and curry as breakfast and eat it at her workplace. She used to reach home by 7 or 8pm after which she would cook dinner of rice and curry, eat and sleep by 11pm.
After she got sick, she stopped going to work and stayed at home, following which she was admitted into the hospital.
Past History:
No similar complaints in the past
k/c/o DM since 2 years (TAB.GLIMI 1 mg)
k/c/o HTN since 2 years on medication
h/o CVA 2 years ago(infarct in brain)
Not a k/c/o CAD, TB, asthma,epilepsy,thyroid disorders
Surgical history:
h/o renal calculi surgery 15 years ago
Personal History:
- married
-appetite normal
- mixed diet
- regular bowels
- normal micturition
- no known allergies
- addictions: was a chronic smoker, but stopped 15 years ago
Family History: not significant
Drug History:
TAB.GLIMI 1mg
General Examination:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and moderately nourished
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals:
- Temperature: afebrilePulse:96 beats/min
- RR:18 cycles/min
- BP:150/80 mm Hg
-SPO2 :98%
Systemic Examination:
Respiratory System
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present
- No wheeze
Cardiovascular System:
Inspection :
- shape of chest : elliptical
- no engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- bowel sounds:yes
- genitals: normal
- speculum examination :normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Investigations:
Hemogram:
Urine examination:
HIV 1/2 Rapid Test:
HBsAg-RAPID:
Anti HCV Antibodies -RAPID:
Blood Sugar- Random:
RFT:
LFT:
USG:
2D ECHO
ECG:
Provisional Diagnosis:
1.Chest pain under evaluation
2.Renal calculi
3.k/o Hypertension
4.k/o DM
5.k/o CVA
