General medicine 2

 

CASE SHEET:

A 30 yr old female patient came to opd with chief complaints chest pain and pain at back of chest 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6 months back,then she developed chest pain which was episodic for every 15 days,pain was aggregating while breathing and doing work,and reliving during medication, pain was radiating towards the back of chest 

PAST HISTORY:

She had undergone with hysterectomy 6 years back 

N|K|C|O  Hypertension, Diabetes, epilepsy, asthma, TB

FAMILY HISTORY:

Not relevant

Drug history:

Nil

PERSONAL HISTORY:

Diet : Mixed

Appetite : normal

Sleep: inadequate due to chest pain

Addictions : Nil

Bowel/ bladder: regular bowel movements/ decreased urine output

Allergies: nil

GENERAL EXAMINATION:

Conscious coherent cooperative 

Moderately built

Moderately nourished 

No pallor  

No Icterus  

No Cyanosis 

No clubbing of finger 

No lymphadenopathy

 Pedal edema with pain present while sitting for long time about 30 min,then it was relive  by walking ,it was present from past  6 years

VITALS:

Temperature - afebrile 

Pulse rate - 88 /min

Respiratory rate - 16/min

Blood pressure- 110/70 mm Hg

SYSTEMIC EXAMINATION:

A. CaARDIOVASCULAR  SYSTEM ;- 

No thrills

No cardiac murmurs

Cardiac sounds: S1 & S2

B. RESPIRATORY SYSTEM;-

No dyspnea

No wheezing

Vesicular breathe sounds

C.ABDOMEN;-

No tenderness

No palpable mass