A 40 Year old women with chest pain

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.
Pt came with a c/o of
 chest pain since 1 day

HOPI-
pt was asymptomatic 1day ago then had chestpain after having tea which is burning type,non radiating, aggravats after intake of food during that episode she have sweating and palpitations  and also had 1 episode vomiting which contains food ,non projectile,non bilious then had sob (grade 2-3) 
H/o pain over epigastric region which is burning type ,non radiating
H/o weight loss from past 2months
no sweating,no pedal edema
Past history
Not a k/c/o htn,dm,tb, epilepsy,cad, thyroid 
H/o similar complaints of chest pain 10-15 days back for which she sought medical help was found to have anemia for which iron sucrosee injection were given 
H/o palpitations on walking and sob on exertion since 2yrs

Personal history
Diet mixed 
Appetite normal
Bowel and bladder -regular
General examination
Patient is conscious, coherent, cooperative
Pallor is present
No icterus, cyanosis, lymphadenopathy,edema of feet


Vital 
Bp 100/70mm hg
Pr 72bpm
Rr 18cpm

Systemic examination
Cvs s1s2 heard,no murmur
Rs BAE present
Pa soft nontender
Cns nfnd
Investigation
ecg
USG
Impression 
Left simple renal cortical cyst
Finding
O/e 11×7mm cyst mid pile left kidney
2d echo
EF 64%
No MR,TR,AR
No diastolic dysfunction 
Good LV function
No rwma

Provisional diagnosis
Acid peptic disease 
Treatment
Iv fluid ns
Tab.Ultracet 1/2  po qid
2/4/23
S
Her chest pain has reduced,low grade fever was noticed only once for which we recommended tapid sponging and now she is afebrile (98.4f)
O 
Pt is c/c/c
Pr 84bpm
Rr 18 cpm
Bp 90/60mm hg
Grbs 99mg/dl
Cvs s1s2 heard no murmur
Cns nfnd hmf intact
Rs BAE present nvbs
P/a soft nontender

A
Acid peptic disease 

P 
Tab.Ultracet 1/2 qid
Tab.neurobion forte po /oD/Hs


4/5/23
S:
Her chest pain has subsided 
No fever spikes 
Stools passed 

O :
Pt is c/c/c
Pr :78bpm
Rr :16 cpm
Bp :90/60mm hg
Grbs:88mg/dl

Cvs :s1s2 heard ,no murmur
Cns :nfnd hmf intact
Rs :BAE present ,nvbs
P/A:soft ,nontender

A:
Acid peptic disease 

P 
1)Tab.Ultracet 1/2 qid
2)Tab.Pan 40mg/Po/OD before food 
3)Tab.neurobion forte po /oD/Hs

5/5/23

S:
Her chest pain has subsided 
No fever spikes 
Stools passed 

O :
Pt is c/c/c
Pr :78bpm
Rr :16 cpm
Bp :90/60mm hg
Grbs:88mg/dl

Cvs :s1s2 heard ,no murmur
Cns :nfnd hmf intact
Rs :BAE present ,nvbs
P/A:soft ,nontender

A:
Acid peptic disease 

P 
Tab.Pan 40mg/Po/OD before food

Comments

Post a Comment

Popular posts from this blog

A 40 YRS OLD FEMALE WITH ACUTE PANCREATITIS

Image
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. A 40 yrs old female came to opd with chief complaint of  acute history of pain abdomen & vomiting’s since 4 days   HOPI Patient was apparently asymptomatic 4days back now presenting with complaints of pain abdomen originated at left hypochondrium and lumbar region (VAS 7 score) then became diffuse in type over 10 to 12 hours (VAS 10 Worst pain she ever had), squeezing type of pain with occasional coliky type, associated with vomiting’s 2-3 episodes non bilious , non-projectile, non-blood tin
Read more

35 yrs old M with yellow discoloration since 1week

Image
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 . This is a case of 35yr old presented to casuality with the complaints of yellowish discolouration of eyes since 1 week, Dark coloured urine since 1 week. HOPI:                 He was apparently asymptomatic 1
Read more

50 year old male with stroke

Image
  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 patient's 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 the comment box is welcome.” A 50year old male patient  from   naryanapuram   Presented to casualty(29-06-22)with the chief complaint  of  giddiness and weakness in both lower limbs since afternoon .               HOPI: Patient was apparently asymptomatic 1day back then he developed headache and dizziness for 30min on and off  i n the early morning but still he went to perform  his daily work activities (i.e.agriculture) from the afternoon then he had  a deviation of mouth towards right side wit
Read more