med opd case 2

November 03, 2023

A 43 YEAR OLD FEMALE CAME WITH THE CHIEF COMPLAINTS OF CHEST PAIN SINCE 3 DAYS,REFFERED SHOULDER AND BACK PAIN

This is an online E log book by Ebrahim Badshah to discuss my 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments 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. 

CHIEF COMPLAINTS:

A 43 year old female came with the chief complaints of:
- chest pain since 3 days , reffered shoulder and back pain 

HISTORY OF PRESENT ILLNESS: 

The patient was apparently asymptomatic 3 days back. She then complained of pain , throbbing type,insidious onset,gradually progressive with reffered pain to shoulder and back on left side.Shortness of breath also felt
She also complained of bloating and abdominal pain along with burping since 1 year 
No aggrevating and et factors.
No history of vomiting,diarrhea, constipation
No history of night sweats and chills and rigors.
No history of headache
No history of burning micturition

PAST HISTORY:
Patient is a known case of diabetes mellitus 12 years ago, hypothyroidism 20 years ago and hypertension 7 months ago

Not a known case of tuberculosis, epilepsy, coronary artery disease, cerebrovascular accidents.
No similar complaints in the past
No previous surgical history

PERSONAL HISTORY:


Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: decreased
Habits: nil
No history of allergy.
Menopausal, LMP:4 years ago

Family history:
Insignificant

Drug history: 
Tab. Metformin and glimerpiride for diabetes
Tab. Diclofenac for pain relief
Tab. Thyroxine sodium for hypothyroidism
Tab. Telmisartan for hypertension 


GENERAL EXAMINATION: 

The patient is examined in a week lit and well ventilated room
Moderately built and moderately nourished
 pallor present
Pedal edema of pitting type present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration

VITALS:

Temperature: afebrile

Pulse: 74 beats per minute, irregular

Respiratory rate: 16 cycles per minute

Blood pressure: 110/70 mm of Hg

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