A 60YR OLD FEMALE WITH SOB AND CHEST PAIN

 This is an online E log book to discuss our patient's   

de-identified health data shared after taking 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.

MUSKAAN GOYAL ,

ROLL NO. 92


September 29 , 2021

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 diagnosis and treatment plan.

CASE DISCUSSION:

A 60yr old female  who is a known hypertensive since 6 years and a chronic smoker,  came to Opd on 28/9/2020 with complaints of

SOB SINCE 2 WEEKS 

CHEST PAIN ( BURNING TYPE) SINCE 2 DAYS

HISTORY OF ILLNESS:

pt. was apparently asymptomatic 10 years back  then she had developed lower back pain  interfering with her daily life which made her visit a doctor at hospital1 in hyderabad where was told she has osteoporosis , for which she uses calcium supplements and MSAIDS .

she then developed pedal edema nd burning micturation 1 yr back for which she visited the doctor at same hospital 1 where  they found that she has  distal  ureteric calculus  and dilated pelvicalyceal system i.e had mild to moderate hydroureteronephritis on right side., for this she hasnt used any medication. 

she has been complaining of SOB since 1 year which was on and off grade 2 which progressed to grade 3 which has now aggrevated since 2 weeks . she has been taking some injections for it near her place. sob decreased on supine position  and aggrevated on walking. this is also associated with chestpain which is on and off.

no h/o decreased urine output or fever or any other complaints.

she is a known hypertensive since 6 years and is using cilacar10mg plus furosemid and spirinolactone.

personal history:

DIET: mixed

appetite: normal

sleep: adequate

bowel and bladder: regular.

no known drug and food allergies

addiction: smoking.

FAMILY HISTORY:

not significant

GENERAL EXAMINATION:

c/c/c

central obesity present

moon facies present

pallor: absent

icterus: absent

clubbing: absent

cyanosis: absent

lymphadenopathy: absent

edema: absent

senile pururae presen





vitals at time of admission:

temperature: afebrile

RR: 23cycles/min

PR: 60bpm

BP: 110/70

spo2: 98%

SYSTEMIC EXAMINATION:

CVS: s1 s2 heard, no added murmures

CNS: intact

RESPIRATORY: BAE+, NVBS  PRESENT'
per abdomen: not distended, no organomegaly.

INVESTIGATIONS:

1, XRAY CHEST




2, ECG: 


 3, 2DECHO :



4, USG ABDOMEN:


5, BLOOD PROFILE , APTT,RBS.LFT

DIAGNOSIS:

SOB UNDER EVALUATION ,

K/C/O  HYPERTENSION

K/C/O OSTEOPOROSIS OF SPINE

K/C/O RIGHT URETERIC CALCULUS


TREATMENT:








Vidoe of presentation.

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