55 year old male with chest pain since 6 months

 This is an a 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 evident based input.

This E blog 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 diagnosis and treatment plan.

CASE:

A 55 year old male patient resident of peddavoora came to casuality to chief complaints of chest pain since 6 months and shortness of breath since 6 months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 13 years back then he had an episode of fainting with chest pain to which he was taken to a hospital where he was diagnosed with inferior wall myocardial infarction and a blockage in obtuse marginal artery and left circuflex artery he underwent percutaneous coronary intervention. He then started drinking alcohol after 9 years. Then after 10 years he again developed chest pain for 2 days he went to the hospital where he was diagnosed with restenosis of the arteries to which he was treated accordingly by percutaneous transluminal coronary angioplasty with drug eluting stent to LCX and percutaneous old balloon angioplasty to obtuse marginal artery. Then he started drinking again and stopped using his medications 2 years back and later on developed chest pain again to which he consulted a local doctor who advised him to stop drinking alcohol which he stopped but the pain didnt suffice. Pain is dull, mild, retrosternal.

PAST HISTORY:

K/c/o Diabetes since 15 years on mediaction

K/c/o Hypertension since 15 years on medication

No history of Asthma, Epilepsy, Tuberculosis

DRUG HISTORY:

Atorvastatin 40mg

Ecospirin 150mg

Monit gtn 2.6mg

Glucored Forte 

Clopilet 75mg

PERSONAL HISTORY:

Diet: Mixed

Apetite: Normal

Bowel movements: Normal

Bladder movements: Normal

Sleep: Adequate

history of drinking alcohol from past 20 years

no other addictions

FAMILY HISTORY: No known such cases in family

GENERAL EXAMINATION:

Patient was consious, coherent and cooperative, Well oriented to time, place and person.

Pallor- absent

Icterus- absent 

Cyanosis absent 

Clubbing- absent 

Geheneralized lymphadenopathy-absent

Bilateral pedal edema- absent





VITALS:

Temperature- 98.8 F

Pulse rate- 76 bpm

Blood pressure- 140/90 mm Hg

Respiratory rate- 20 cpm

Spo2-98%

SYSTEMIC EXAMINATION:

Cardiovascular system: S1, S2 heard no murmurs heard

Respiratory system: Normal vesicular sounds heard, bilateral air entry present.

Abdomen: Soft and nontender, no hepatomegaly, spleen not palpable.

Central Nervous System: No focal neurological deficits 




INVESTIGATIONS:

Coronary artery angiography

Ultrasound

2D Echo

Complete blood picture

Glucose random blood sugar

Electrocardiogram

PREVIOUS PTCA REPORT:








Comments

Post a Comment

Popular posts from this blog

A 45 year old male with chest pain

Image
Patient came with chief complaints of chest pain 1 episode 6 days back Patient was apparently alright 10 to 12 years when he developed increased drowsiness for which he consulted a doctor and was diagnosed to have hypothyroidism for which he used medication for 2 to 3 years and stopped it.he developed generalised body pains more on the neck and back insidious in onset, intermittent aggravated on working and relevied on taking rest.  Then 1 week back after his dinner (non veg) he started feeling tightness in his chest(like acidity in patients words) and started feeling hot and his breath became heavy for which he tried to on the fan and became unconscious as he got up. The pain was localised non radiating. When he got unconscious his family members observed that he was profusely sweating and pass urine involuntarily following which his family members took him to the hospital for which treatment was done for coronary artery disease, acute inferior wall mi with EF 45% He later got con...
Read more

MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE

 MAY 30TH 2023 This in Harthik choppa a medical student from India. Welcome to my blog where you can see how my general medicine changed my view of seeing general medicine as a mere subject which has to be studied for the sake of exams to general medicine being an interesting, immersive journey which covers each and every aspect of our amazing human body. We had an open platform where we could discuss things and we approached our HOD sir and seniors directly many times where our doubts were cleared with an open mind without any judgement. As medical students we learned a lot of different ways to diagnose and treat a patient in different scenarios practically bedside rather than studying books for hours and hours. I am very much excited to share this journey over the past 3 years Coming to my first case,  It was a 65 old female who was quite alright when I saw her my first impression on the lady was she is perfectly alright so I was intrigued on why she came to the hospital as ...
Read more

60Y old male with sob, abdominal distention and bilateral pedal edema since 4 days

Image
  Patient came with chief complaints of shortness of breath since 4 days, pedal edema since 4 days and abdominal distention since 4 days Patient was apparently asymptomatic 5 years back when he had an injury to the left leg by a thorn prick for which doctor advised him to keep ice over it. He did this for 5 days when he noticed swelling accompanied by blebs. Swelling was localised and associated with pain which was non radiating, no know aggravating or releiving factors for which he was admitted and dressing was done for 1 week and later ok discharged after the swelling had reduced. During this visit to the hospital he was given a pint of blood transfusion due to decreased heamoglobin count. The patient complains of neck pain from 10 years has history of lifting heavy weights on shoulders, non radating, no known aggravated and releving factors. Some releif on using collar. Use it when he is unable to bear it. H/o knee pain since 10 years bilateral non radiating aggravates on walkin...
Read more