70 year old Female patient with Fever, Left sided Chest Pain and Vomiting

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Bhavana Chenna,

9th semester,

Roll No :- 20.

Case Discussion :-

I have been given this case to solve in an order to 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.

A 70 year old Female came to the Hospital on January 5 with the-

Chief Complaints :- 

* Fever since 1 day

* Left sided chest pain since yesterday night. 

* Vomiting since today morning with 1 Episode  at 4 am.

History of Present Illness :- 

* She was apparently Asymptomatic 1 day back and then she developed :-

* Fever which is of Low Grade, Insidious in Onset, Continuous and relieved on taking Medication and Not associated with Chills and Rigors.

* Left sided Chest pain which is Pricking type   of pain, Radiating to the left hand, associated with sweating, heaviness to the chest and chest tightness.

* Vomiting in the morning at 4am had Non Projectile, Non Bilious, Non Foul smelling and contains Food particles.

History of Past Illness :- 

* In 2007 she had similar complains PTCA (LCX territory)---> triple vessel disease LCX, RCA CABG done. 

* In 2017 similar complaints admitted in NIMS, conservatively treated.

* K/c/o diabetes and hypertension since 15 years.

* Not a known case of Epilepsy, Asthma, Thyroid disorders.

Drug History :-  

* Vildaglitan 50 mg 

* Metformin 500mg 

* Telma 40 mg.

Family History :-

No History of Diabetes mellitus, Hypertension, Asthma, Tuberculosis, Epilepsy, Thyroid disease and CAD in the Family.

Personal History :-  

Diet: Non Vegetarian

Appetite: Normal

Sleep: Adequate

Bowels & Bladder movements: Regular

Addictions: Absent

Physical Examination :-

A. General Examination :- 

* Patient is Conscious, Coherent, Co-operative. 

* She is well oriented to time, place and person.

* She is Moderately Nourished.

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent

B. Vitals :- 

Temperature: Febrile

Pulse rate: 80 BPM

Respiratory rate: 15 CPM

Blood pressure: 130/80 mm of Hg

SPO2: 100%

C. Systemic Examination :-

Respiratory System :- 

* Position of Trachea - Central

* Bilateral Air Entry +

Per Abdomen :- 

* Abdomen is Soft and Non Tender and Non distended.

* No Organomegaly.

* No Palpable mass or Fluid present.

Central Nervous System :- 

* Patient is Conscious.

Cardiovascular System :-

Inspection:- Normal   

* Previous Surgery scar present

Palpation:- 

Normal

Auscultation:-

* SI, S2 heard. No murmurs 

Investigations :-

09/01/2022

Diagnosis :-

Diabetic Ketoacidosis with Anteroinferior  Wall Myocardial Infarction which is Non-ST   Elevated  Myocardial Infarction.

Treatment :-

1. Injection HAI 1 ml (40 U) + NS 39 ml at 8 ml/hr to maintain GRBS less than 200 mg/dl

2. IVF. 1 unit NS continuous infusion at urine output + 30ml/hr

3. TAB ECOSPRIN 75 MG PO OD 

4. TAB CLOPIDOGREL 75 MG PO OD

5. TAB ATORVASTATIN 40 MG PO OD

6. TAB CARDIVAS 3.125 MG PO BD

7. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS

8. TAB MONIT GTN 2.6 MG PO OD