A 41 year old female came with chief complaints of pain in left chest region and left arm.

General medicine E-Blog

Hi, I am N .Annmaria , 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 from Velmuru village came to medicine OPD with chief complaints of pain in left chest region and left arm.

HISTORY OF PRESENTING ILLNESS

Patient was apparently assymptomatic 5 months ago.

Then she developed shortness of breadth which was insidious in onset and gradually progressive and increased during sleep.

Associated with easy fatiguability since 5 months.

She developed pain in left mammary region and pain is radiating to left arm since 4 months.

Pain is also associated with chest tightness and abdominal discomfirt.

Pain is dragging type and increased after intake of food.

Abdominal discomfirt is relieved by intake of pantaprazole tablet.

She also developed low grade fever since 2 days.

No history of vomiting, headache and photophobia.

Her age of menarche was at 13 years.

Duration of cycle was 28 days and number of days of bleeding was 5 days.

She has amonnorhea since 4-5 years. 

HISTORY OF PAST ILLNESS 

She was a known case of hypothyroidism since 7-8 years.

She had undergone blood transfusion of 2 bottles after child birth 

No h/o HTN, DM, Asthma, CAD, TB, Epilepsy

FAMILY HISTORY

Her father had a heart condition.

Her mother has diabetes mellitus and hypertension.

PERSONAL HISTORY

  Married

  Mixed diet

• Normal appetite 

• Adequate sleep

• Bowel and bladder movements regular

• No Allergies

• No Addictions

General Examination

• The patient was conscious

• Well oriented with time, place and person

• Cooperative and coherent

• Pallor present

• No icterus

• No cyanosis

• No clubbing of fingers

• No lymphadenopathy

• No pedal oedema

VITALS

PR-110 bpm

Temp- afebrile

BP- 110/60

RR- 28 cycles per minute

LABORATORY INVESTIGATIONS