A 60YR OLD FEMALE WITH SOB AND CHEST PAIN
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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
SOB UNDER EVALUATION ,
K/C/O HYPERTENSION
K/C/O OSTEOPOROSIS OF SPINE
K/C/O RIGHT URETERIC CALCULUS
TREATMENT:
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