55 years old female with chest discomfort.
December 10,2022
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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. 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.
A 55 year old female patient who is from nalgonda and farmer by occupation presented to OPD on 10/12/22 with
Cheif complaints of
-Neck pain since 15 days
- fever since 10 days
- chest discomfort since 10days
- burning micturition.
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 15 days back then she developed neck pain which is non radiating and then developed low grade fever which is intermediate type which is subsided on taking medication and since 10 days chest pain which is non radiating.
and suffering from burning micturition
PAST HISTORY:
Not a K/c/o DM, HTN, TB, Asthma, Epilepsy and CAD.
Hysterectomy done 20 years back.
FAMILY HISTORY:
No similar complaints in family
PERSONAL HISTORY:
APPETITE:Decreased since 10 days
DITE:mixed
SLEEP:Adequate
BOWEL AND BLADDER: regular
MICTURITION:normal
No addictions.
DRUG HISTORY:
No relevant drug history.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative, well oriented to time and place.
Pallor-absent
Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
TEMP:99.6F
BP:110/80mmhg
RR:20 cpm
PR:92 bpm
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM:
No Thrills,
S1,S2 sounds hears,
No murmurs.
RESPIRATORY SYSTEM:
NO Dyspnoea
NO Wheeze
Trachea in Central position
Vesicular breath sounds
ABDOMEN:
INSPECTION:
shape-scaphoid
Flanks-free
Umbilicus-invertedand central position
Hernial orifices-nornal
No dilated veins
No scars and sinuses
PALPATION:
Non tender
No Local rise of temperature
No palpable Mass
Spleen and liver not palpable
AUSCULTATION:
Bowel sounds-present
PROVISIONAL DIAGNOSIS:
?Acute gastritis
INVESTIGATIONS
X ray:
ECG:
10-12-22 at 12:47 pm
10-12-22 at 7:15 pm
TREATMENT:
Tab.PCM 650 mg/PO/TID
Tab.PAN 40mg/PO/OD
Tab.MVT/PO/OD
Tab.ULTRACET/BD
INJ. NEOMOL 1gm IV
(If temp is greater than 105 F)
(If temp is greater than 105 F)
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