A 37 year old female with body pains and post MI

This E blog 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 diagnosis and treatment plan.

CASE:

A 37year old women, housewife who is a resident of Kolkata came with the chief complaints of pain in the back of the neck and lower back since 1year and chest pain 2 weeks back.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 years back then she had

Daily routine:

She wakes up at 6 am and cooks for herself and her family and do her household chores and has breakfast at 9am and lunch at 1pm and dinner at 9pm then sleeps by 10pm.

PAST HISTORY:

she is a known case of Hypertension since 6 years.

K/c/o CVA 6 years back.

She is not a known case of asthma, diabetes,TB.

PERSONAL HISTORY:

Diet-mixed

Appetite-normal

Sleep-adequate

Bowel and bladder movements-regular Addictons-none

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. moderately built and nourished.

Pallor-absent

Icterus-absent

Clubbing-absent

Cyanosis-absent

Generalised lymphadenopathy-absent

Pedal edema-absent

Vitals:

Temperature- degree F

Pulse rate- bpm

Respiratory rate-cpm

Blood pressure -mm of hg

Spo2-%at room air

Grbs-mg /dl

SYSTEMIC EXAMINATION:

Cardiovascular system:

S1 and S2 heard no murmurs heard

Central nervous system:

No focal neurological deficit, cranial nerve intact

Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard

Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable.

Provisional diagnosis:

Post stroke and post MI secondary to hyperlipidemia and Hypertension

Investigations:

ECG:

2D echo heart:

Treatment:

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