35 years old female patient came to casuality

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

35 YEARS OLD FEMALE PATIENT CAME TO CASUALITY WITH 

Chief complaints :

Chest pain  since 6months 

Shortness of breath since 5 months 

History of presenting illness :

Patient was apparently asymptomatic 6months back then she developed chest pain (both right and left side) which is insidious in onset gradually progressive in nature associated with chest tightness. Chest pain and tightness are more after eating food associated with excessive sweating. Then she developed shortness of breath which is insidious onset gradually progressive (grade2 to grade3) .

Orthopnea - present at rest 

No H/o paraoxysomal nocturnal dyspnea 

No H/o giddiness ,pedal edema , cough, cold ,pain in abdomen ,vomiting 

Past history: Not a k/c/o DM,TB , epilepsy,HTN ,asthma 

Personal history:

Married 

Appetite: normal

Bowel and bladder: regular

Addictions : no 

Sleep: adequate 

Family history:  No significant family history 

Treatment history: No significant treatment history 

General examination :

Patient is conscious ,coherent ,cooperative

 Moderately Built and Moderately Nourished 

Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent

 Vitals :- 

Temp: Afebrile 

BP : 140 / 80mmHg 

PR : 73 bpm 

RR : 22cpm 

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection: chest shape normal, 

No scars , no engorged veins 

Movement of chest both sides 

AUSCULTATION :

Bilateral air entry 

Normal vesicular breath sounds 

PALPATION:

Trachea central 

Cvs :

S1,S2 - heard 

No murmur

Abdominal examination: 

Shape : scaphoid

Tenderness -no 

Free fluid -no 

Liver,spleen -not palpable 

CNS: 

Higher mental status intact 

Reflexs are intact 

No focal neurological deficit 

INVESTIGATIONS: 

ECG : 

Chest x ray PA view :

USG :

RFT : 

Hemogram: 

CUE :

LFT : 

Diagnosis : dyspnea under evaluation