A 55yr female with chest pain since 3months
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Intern : N Joshua Paul
A 55yr old female who is a resident of suryapet and home maker by occupation came to medicine OPD with
CHIEF COMPLAINTS:
C/O chest pain since 3months
HISTORY OF PRESENTING ILLNESS:
Patient was apparently alright 3months back then she has chest chest pain , pricking type of pain,radiating to left hand ,associated with SOB grade 2 relieved by taking rest.Not associated with orthopnea,PND.
No c/o pedal edema,decreased urine output
No c/o abdominal pain,vomitings
No c/o polyuria , nocturia
No c/o Fever , cold , cough
PAST HISTORY:
K/C/O DM 2 since 5-6yrs (using metformin 500mg po/bd)
K/C/O recurrent chest pain (?MI) 6yrs back (Ecosprin-AV 75)
K/C/O thyroid disorders 15yrs back (using thyronorm 25mcg)
Angiogram was done in 2019
PRESENT HISTORY:
Diet-mixed
Appetite-normal
Sleep -regular
Bowel and bladder movements-regular
Addictions-nil
FAMILY HISTORY:
No significant family history
GENERAL AND PHYSICAL EXAMINATION:
Patient is conscious,coherent,cooperative
Moderately built and nourished
No signs of pallor,icterus,cyanosis,clubbing,edema,lymphadenopathy
VITALS:
Temperature-97.4F
Pulse rate- 80bpm
BP- 150/80mm hg
RR- 18cpm
SPO2 - 100%at RA
CVS EXAMINATION:
Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system :
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
Per Abdominal examination:
Soft , non tender
bowel sounds heard
CNS examination:
No focal neurological deficit
Normal speech
Upon admission patient was taken for ophthalmology cross consultation on 13/09/23 I/V/o diabetic retinopathy and hypertensive retinopathy and they gave impression as normal anterior segment and fundus with no features suggestive of diabetic or hypertensive retinopathy.
PROVISIONAL DIAGNOSIS:
Stable angina;
K/c/o hypothyroid since 20yrs
K/c/o HTN and DM2 since 5yrs
INVESTIGATIONS:
Hb- 11.0
PCV-33.7
TLC-6,900
RBC-4.28
PLT count-2.09
Blood urea-26
S.creatinine-0.8
Na+ 138
K+ 3.9
Cl- 99
Ica+ 1.20
Hba1c-6.8%
RBS-184
Albumin-nil
Sugars-4+
Pus cells :2-3
T3-1.00ng/dl
T4-9.47ng/dl
TSH-2.86
TREATMENT:
1)T.Thyronorm 25mcg po/od
2)T.Ecosprin AV 75/10 po/hs
3)T.Glimi M1 po/bd
4)T.Telma 40mg po/od
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