63 year old female patient presented with chest pain since 1 year


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 evident based input..

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

Cheif complaints:
Patient came with cheif complaints of chest painbon and off since 1 year

HOPI
patient was apparently asymptomatic 1 year back then she developed chest pain in the mid chest behind the sternum dragging type, non-radiating associated with palpitations ( the patient explained that she started experiencing this since her husband was affected by a stroke 1 year ago)

No h/o of vomiting, shortness of breath,heartburn,giddiness, sweating,headache

Patient also complains of neck pain since 1 year on and off  non radiating, no tingling sensation,no h/o trauma,heavy weight leaving

Patient also complains of decreased vision since 1 year

PAST HISTORY:
Not a known case of DM/HTN/ TUBERCULOSIS/ASTHMA/

PERSONAL HISTORY:

Appetite: decreased

Diet:mixed

Sleep: adequate

Bowel and bladder are regular

Patient denies of any addictions

FAMILY HISTORY:

no history of similar complaints within the family

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative

Well built and we'll nourished





Pallor: absent 

Icterus:absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: absent
 
VITALS:

BP 140/80
Heart rate 85 bpm
Resp Rate 17/min
Sp02 98%

RS 
BAE+ 
NVBS+ 
no added sounds

CVS 
S1 S2 heard
 no murmurs

P/A 
soft , no tenderness,no organomegaly,

CNS 
Higher mental functions intact 
No focal neurological deficit 

PROVISIONAL DIAGNOSIS 
Chest pain under evaluation

INVESTIGATIONS

TREATMENT
T.PANTOP 40MG PO/OD
T.ZINCOVIT PO/OD

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