General Medicine case Discussion

April 20 , 2023

 General medicine case discussion

E LOG MEDICINE CASE

20/04/2023

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.

Name : Mamatha. N

Roll no : 65

2020 Batch

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 comeup with Diagnosis and Treatment plan.

CASE DISCUSSION

Date of admission:19/04/2023

A 41 year old female patient housewife by occupation,  resident of velmuru came to opd with 

Chief complaints :

 Dragging type of left chest pain radiating to left arm .

History of presenting illness :

Patient was asymptomatic 5 months back. Then she developed shortness of breath suddenly and it was gradually progressed and it increased while sleeping. Shortness of breath is associated with easy fatiguability after work. 

Then 4 months back she developed left chest pain which was insidious in onset and radiating to the left arm . 

Past history :

A known case of thyroid since 7 to 8 years.

On medication  for hypothyroidism .

No DM, epilepsy, TB, asthma, HTN. 

Personal history :

Sleep -  Adequate 

Appetite - Normal 

Diet - Mixed diet 

Bowel and bladder movements - Normal 

Allergies - None 

Addictions - None 

Family history :

Mother has history of DM and HTN. 

Father has heart problems .

General examination :

Conscious 

Coherent 

Well  oriented to time, place and person

Pallor : Present

Icterus : Absent 

Cyanosis : Absent 

Clubbing of fingers : Absent 

Lymphadenopathy : Absent 

Edema : Absent  

Vitals :

Temperature - Normal 

Blood pressure -130/85

Pulse - 75/min

Breath rate - 14 / min