60 year old female with chief complaints of chest pain, SOB and palpitations

Sanjay Bandaru (roll no. 121) and Vanshika Savla (roll no. 122)

3rd sem 

 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 evidence based input.

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 SCENARIO:

A 60 year old female came to the causality with a cheif complaint of chest pain since 2 hrs SOB since 4 hrs, palpation since 4 hrs K/C/O of HTN 

History of present illness:

The patient was asymptomatic morning. Then she planned on a procedure of intra thecal steroid injection for sclera in the afternoon. She took her morning dose of metxl 50 mg clopitab. But the procedure was delayed due to high bp she stopped taking her normal medication ecosprin since 6 days for the procedure. After the procedure was cancelled she came back home and ate lunch she was feeling discomfort and took ecosprin tablet and sorbibate in the evening. She developed 

• fever, chills and rigor 
• h/o chest pain since 1hr
• dry cough since evening
• no history of orthopnea

She took medication of metxal 50mg, ecosprin 150mg and slorbitrate 5mg

History of past illness:

K/C/O HTN

H/O PTCA 

Treatment history:

N/K/C/O Diabetes 

K/C/O HTN 

N/K/C/O CAD

Physical examination :

General:

Temp: 103 F

HR: 60 bpm 

RR: 24/min 

SPO2 93%

BP: 200/100

GRBS: 194

Mild oedema of feet 

Systemic Examination :

RS BAE+

CVS: S1 S2 +

PA: soft and non tender 

CNS: NAD 

Complaints and duration 

C/O SOB grade 3-4 

Palpations: 2 hrs 

Fever and chills: 2 hrs 

Chest pain: 2hrs

INVESTIGATIONS :

                                                        ABG analysis:

                                                         Troponin I :

Serum Electrolyte:

Blood Sugar:

Blood Urea:

Rapid Test

                                                                   ECG

RT-PCR

2D Echo screening

TPR Graphic Sheet (day 1 and day 2)

TREATMENT :

Day 1:

Tab SLORBITRATE 5mg 

Inj CEFTRIAXONE 1gm

Inj PANTOP 40gm

Syrup ASCRIL 15ml 

Tab PARACETAMOL 650 gm 

Inj NEOMAL 100gm

Inj NEUMA 1gm

Tab TELMA 40mg 

Tab CLOPITAB 75mg

 Tab ECOSPIRIN 75mg 

Tab ALORIVAS 20mg 

Tab METXL 50mg

Inj LASIX 40mg

Day 2:

Inj CEFTRIAXONE 1gm (2)

Inj PANTOP 40gm

Tab MET-XL 50gm

Tab TELMA 40gm

Tab CLOPIDOGREL 75gm

Tab ECOSPIRIN 75gm

Tab ATORVAS 20mg

Tab PCM 500gm (3)

Inj NEOMOL 1gm

Tab THYRONEUM 25gm

Neb BUDECORT, MUCOMIST

Syrup ASCORIL (2)