General Medicine Case Discussion

General medicine E-Blog

Hi, I am Krishna Swarali V , 3rd Sem Medical Student.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.”

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 a diagnosis and treatment plan. 

CHIEF COMPLAINT: 
A 41 year old female patient came to medical OPD with chief complaints of pain in the left side of the chest and left arm.

HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 5 months ago.
Suddenly she developed Shortness of breath which is progressive continuously and it increased while sleeping. Shortness of breath is associated with easy fatiguability after work.
She developed pain in the left mammary region and pain is radiating to left arm since 4 months. Pain is associated with chest tightness and abdomimal discomfort.
Pain is dragging type and increased after intake of food. Abdominal discomfort is relieved by intake of pantaprazole tablet.
She also developed low grade fever since 4 days.
No history of vomiting, headache and photophobia.

HISTORY OF PAST ILLNESS
A known case of thyroid since 7 to 8 years.
No DM, TB, epilepsy, asthma

FAMILY HISTORY 
Mother has history of DM and HTN. 
Father has heart problems.

PERSONAL HISTORY
Diet: mixed
Appetite:normal
Sleep:adequate
Bowel: regular
Bladder: normal micturition
No known allergies
Addictions: None

PHYSICAL EXAMINATION

GENERAL EXAMINATION 
conscious and coherent
pallor present
No icterus
No lymphedemopathy
No clubbing of fingers
Edema absent
No malnutrition
No dehydration.

Vitals
BP:110/70
Respiratory rate:28 cycles/min
Pulse rate:110bpm
Temp: afebrile

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