55 Year Female with chest pain since 3 months

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I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Presenting complaints:

Patient came to GM OPD with chief complaints of chest pain since 3 months

HOPI:

Patient was apparently asymptomatic 3months back then she has chest pain, pricking type of pain , radiating to left hand intermittently associated with shortness of breath intermittently grade 2 relieved by taking rest not associated with orthopnea,PND.

No h/o pedal Edema, decreased urine output.

No h/o abdominal pain, vomitings.

No h/o polyuria,nocturia.

No h/o fever,cough,cold

Past history:

K/C/o diabetes mellitus type 2 since 5years using Metformin 500mg po/BD

K/C/o recurrent chest pain 6 years back using ecospirin AV 75

K/C/o thyroid disorders since 20 years using thyronorm 25mcg

Angiogram was done in 2019

Personal history:

Appetite normal

Sleep adequate

Bowels regular

Micturition normal

General physical examination

Patient is conscious coherent and cooperative

PR 80 BPM

BP 150/90 mm hg

RR 18 cpm

GRBS 235 mg/dl

Pallor present

No icterus, cyanosis, clubbing, lymphadenopathy, Edema

Systemic examination

CVS s1s2 heard ,no murmurs heard

RS Bilateral air entry present, NVBS

P/A soft ,non tender

CNS HMI, NFND

DIAGNOSIS

Stable Angina

K/C/o hypothyroid 20 years

K/C/o diabetes mellitus type 2 since 5 years

K/C/o hypertension since 5 years

Treatment

1.Tab  thyronorm 25 MCG po/od

2.Tab ecospirin AV 75

3.Tab Metformin 500 mg po/BD

4.Tab Telma 40 mg po/od