70 YEAR OLD FEMALE WITH FEVER AND LEFT SIDED PAIN

 T.shivani 

MBBS 9th semester

Roll no:06

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

I’ve 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 .

Following is the view of my case..

70 yr old female with fever and left sided chest pain .

January 11, 2022

A 70 year old female came to casuality on 05-01-2022 with 

Cheif complaints:-

*fever since 1 day. 

*Left sided chest pain since yesterday night and vomiting since 5th Jan morning 1 episode at 4 am.

History of presenting illness:-

She was apparently asymptomatic 5 days back and then she developed 

1. Fever, lowgrade, continuos relieved on taking medication - not associated with chills and rigors
2. Left sided chest pain - radiating, pricking type of sensation to the left hand, associated with sweating, heaviness to the chest and chest tightness present.
3. Vomitings in the morning at 4am - non projectile, non bilious, contains food particles and non foul smelling.

PAST HISTORY:

1. Patient is a known case of diabetes and hypertension since 20 years. 
2. Patient is using vildaglitin(50 mg) and metmorfin(500mg) and telma(40 mg). Patient is regular with medication. 
3.  2007, patient had similar complains, and had a PTCA with stent implantation. She was diagnosed with triple vessel disease. 
4.  2015, RCA CABG done, when patient had a repeat of similar complaints. 
5. 2017, patient again had similar complaints, was admitted in NIMS, and conservatively treated.
6. Patient has no history of thyroid, Tuberculosis or asthma. 

FAMILY HISTORY:

Not significant. 

PERSONAL HISTORY:

1. Diet: Mixed 
2. Appetite: Normal
3. Bowel and Bladder: Regular 
4. Sleep: Adequate 
5. No Allergies. 
6. Occasional Alcohol intake. 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. Well oriented to time and space. Moderately built and moderately nourished. 

After taking informed consent and in a well lit room, examination was conducted. 

No pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy, or edema. 

Vitals:

PR- 84 bpm

BP- 130/80 mmHg measured in the left upper limb in the supine position 

RR- 15 cpm

Temp- Afebrile

Fever chart: 

Day 2: 6th jan

S: nausea,generalised weakness

No fever spikes

Pt complaining of chills

Bp :140/90mmhg

PR: 90bpm

RR : 18

Spo2 : 99% at room air

Pt is on insulin infusion since yesterday,

She had 2 episodes of hypoglycemia

Anion gap reduced (31.7 to 21)

Still continuing infusion at 2ml/hr

Day 3 : 7th Jan 

 

S: nausea reduced ,generalised weakness

One fever spike @6pm 

Temp 100.6 F 

Bp :140/80mmhg

PR: 82bpm

RR : 18

Spo2 : 99% at room air

 insulin infusion stopped,

No episodes of hypoglycemia

Input/ output: 1100/1000 ml

SYSTEMIC EXAMINATION:

• CVS

1) Inspection: 

Chest wall is symmetrical

 No dilated veins, scars and sinuses. 

 No visible apical pulse 

 No visible pulsations

Visible scar is present on the midline. 

2) Palpation: 

Apical Pulse: Normal in the 5th intercoastal space, 1cm lateral to the midclavicular line. 

No palpable pulsations

3) Percussion

Heart Borders can be percussed normally. 

4) Auscultation: 

S1, S2 sounds are heard. 

No abnormal heart sounds heard 

• RESPIRATORY SYSTEM

1) Inspection: 

- Chest is symmetrical

- Trachea is in the midline 

- No drooping of shoulders

- No sinuses and dilated veins

2) Palpation: 

- Trachea – midline

- No dilated veins

- Chest movement is symmetrical

3) Percussion: 

                                      R                        L 

Infraclavicular     Resonant       Resonant

Mammary.            Resonant        Resonant 

Axillary.                 Resonant        Resonant

Infraaxillary         Resonant        Resonant

Suprascapular     Resonant         Resonant

Infrascapular       Resonant        Resonant

4) Auscultation: 

-Breath sounds: Normal Vesicular Breath sounds

- No added breath sounds 

• ABDOMINAL EXAMINATION

1) Inspection: 

- Shape: scaphoid, not distended

- Flanks: free

- Umbilicus: midline, inverted

- Skin: not stretched, shiny, no scars, sinuses, striae

- No dilated veins

- No abnormal movements of the abdominal wall, visible peristalsis, 

2) Palpation: 

- No local rise in temperature, no tenderness 

- Soft on touch

3) Percussion: 

- No fluid thrill, shifting dullness

4) Auscultation: 

- Normal bowel sounds heard 

• CNS 

- Normal higher mental functions 

- No focal neurological deficit

- All higher motor functions are normal 

 

Investigations:

TROP - 1 is positive.

ECG:-

05-01-2021

06-01-2021

07-01-2021

2D echo :

Usg abdomen report:

DIAGNOSIS:

DKA with anteroinferior wall MI 

TREATMENT:

1. Inj. HAI 1 ml (40 U) + 39 ml NS 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 ECOSPORIN 75 MG PO OD 

4. TAB CLOPIDOGREL 75 MG PO OD

5. TAB CARDIVAS 3.125 MG PO BD

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

7. TAB MONIT GTN 2.6 MG PO OD

8.TAB ATORVASTATIN 40 MG PO BD