A 55 yr old female patient c/o epigastric pain c/o neck pain and knee pain.
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I have been a case in order to make my skills better in understanding the "Patient's clinical data analysis". Making a note of all the necessary information like the history of patient's present illness, his medical history, his family history, diagnosis and treatment plan.
Cheif complaint:
Patient came with a complaint of pain in the epigastric region since 1 year
Knee pain since 4 months
Neck pain since 10-15 days.
History of present illness:
Patient was apparently asymptomatic one year back, then she developed pain in her abdomen especially after eating.
No vomitings or diarrhea was seen.
The pain was radiating to the chest and she also felt burning sensation.
She went to a local doctor and used some medication but the pain was not relieved.
She also developed pain in her knees bilaterally since 4 months and also appreciated slight swelling of her knees. Pain was apprevating on work.
She also developed neck pain 10-15 days back which was radiating to the shoulder.
Patient also have dialated veins in her right leg in the lower part since delivery of her first child that is apparently since 35 years ago.
History of past illnesses:
No history of Diabetes
No history of hypertension
No history of thyroid
No history of asthma
No previous trauma
Personal history:
Patient is married.
Daily routine: Patient works as a daily labour in the agriculture farms. She goes to work at 9 am in the morning and returns home at 5 pm in the evening.Working since 40 years.
Appetite - normal
Diet - non vegetarian
Bowel movements - normal
Micturation - normal
Sleep - adequate.
No addictions.
Menstrual history:
Age of menarche - 15 yrs
Menstrual cycle - 27 days
Age of menopause - 45 yrs
No.of children - 5
Patient has undergone tubectomy.
General examination:
Patient is thin built and malnurished.
Patient is conscious, coherent, cooperative and well orientated with the place and time.
No pallor, icterus, cyanosis, clubbing seen.
No generalized lymphadenopathy.
Vitals:
On 18-01-2023 :
Temperature - 96.4F
Respiratory rate - 16 cycles/ min
BP - 110/80mmhg
Pulse - 88beats / min
SPO2 - 96%
GRBS - 100 mg.
On 19-01-2023 :
Temperature - 101F
Respiratory rate - 21 cycles/min
BP - 120/80 mmhg
Pulse - 94 beats/ min
Systemic examination:
CVS examination-
Inspection :
Chest wall is symetrical
No scars are seen on chest
No dialated veins.
Palpation :
No thrills are felt.
JVP - slightly raised.
Parasternal heave is felt on left side.
Percussion :
Heart borders are appreciated,
Auscultation:
Mitral area - S1, S2 heard.
Apex beat is heard at the 5th intercoastal space.
Respiratory examination-
Wheeze is heard over the upper sternal area.
Vesicular breath sounds are heard.
Provisional diagnosis :
Chest pain and CAD under evaluation,
Right bundle branch block and c/o Posterior wall MI and c/o Right ventricular hypertrophy.
Bilateral osteoarthritis.
Peptic Ulcer disease.
Varicose veins.
Investigations:
X - rays -
Blood sugar - 109 mg/dl
Blood urea - 24 mg/dl
Serum creatinine - 0.7 mg/dl
Liver function tests :
Total bilurubin - 0.69 mg/dl
Direct bilurubin - 0.17 mg / dl
SGOT - 41 IU / L
SGPT - 40 IU/ L
Alkaline phosphate - 192 IU/ L
Protiens - 69 gm/ dl
Albumin - 4.2 gm/dl
ECG :
18-01-2023-
19- 01-2023 -
2D Echo -
Treatment :
Tab Pantoprezol 40 mg before breakfast
Tab Ultracet
Tab Met- xl 12.5 mg
