A 45 YEARS OLD FEMALE PATIENT WITH PALPITATIONS, PEDAL EDEMA, CHEST PAIN,CHEST HEAVINESS,RADIATING PAIN ALONG LEFT UPPER LIMB

This is an online E log book to discuss our patient's  de-identified health data shared after taking 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 patient's 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 the comment box is welcome.

Entire history was taken through telecommunication with patient guardian

B.Omnivas Guptha

Roll no:12

Case discussion:

A 45 years old female ,house wife by occupation came to opd with chief complaints of palpitations,chest heaviness,pedal edema,chest pain,radiating pain along her left upper limb , generalized body weakness

Cheif complaints:

*She complains that  she could feel her own heartbeat since 5 days and it is more rapid since yesterday night.

*Pain along her left upper limb associated with tingling and numbness-6 days

*Chestpain -since5 days

*Difficulty in breathing-5 days

*Swelling over the legs(bilateral)-8 months

History of presenting illness: patient was apparently normal 8months back then she developed bilateral pedal edema which is gradually progressing and it is present both in sitting and standing position and relieved on taking medication.

Palpitations: since 5days which are sudden in onset,more during night time and aggregated by lifting weights, speaking continuously and it is relieved by drinking more water, medication

*dyspnoea during palpitations (NYHA-CLASS-3)-since5 days

*Pain:since 6days radiating along the left upper limb which is dragging in nature, aggrevated during palpitations and relieved by taking medication for palpitations.

*Chest pain associated with chest heaviness

Negative history: No-fever, vomiting, diarrhoea,muscle pain

Trauma history:Absent

Past history:blood infection -7 months back

Past reports:


*(right and left)paresis due to hypokalemia 1year back

2 months back came to KIMS NARKETPALLY for treatment of neck pain for which she received medication:




10 yrs back had the episode of paralysis of both upper and lowerlimbs(rt and left)

Not a k/c/o-(diabetes , hypertension,asthma,TB, epilepsy)


Drug history:notsignificant; 

family history:not significant

surgical history:not significant

Personal history:

Diet : mixed

;Appetite:normal;

Bowel movements-irregular

; bladder movements-normal;

Sleep: Inadequate (due to palpitations, dyspnoea,chest heaviness)

Addictions:no addiction

PHYSICAL EXAMINATION:
Patient is conscious coherent and cooperative

Well oriented to time place and person

Moderately built and moderately nourished 
Vitals:

Temperature: Afebrile

Pulse rate:78bpm

Bp:130/80mmHg

No-(pallor,icterus, clubbing, cyanosis,  generalisedlymphadenopathy)

Edema:pedal edema(pitting type)


Systemic examination

  1. RESPIRATORY SYSTEM : Normal Vesicular Breath Sounds Audible,B/l air entry present
  2. CVS : S1 and S2 Heard,no murmurs
  3. PA : Soft, No Tenderness, No Hepatomegaly or Splenomegaly
  4. CNS : Intact

Investigations:CBP,CUE, 2D ECHO CREATININE,RFT,CHEST -XRAY

CBP:


CUE:


COLOUR DOPPLER-2DECHO

creatinine

RFT


CHEST X RAY(DONE ON 14-3-21) done for neck pain.



Ecg:
Present treatment history:
Hospital 1:14/5/21
TabLassix-40mg(PO-OD)
TabMVT((PO-OD)
TabShelcal(PO-OD)
Hospital 2:(15/5/21)due to severity of palpitations,chestpain went to hospital2
Tab Flupertin :PO(BD)
Cap Clobitab:PO(OD)
Cap Azithromycin:PO(OD)
Tab Dexamethasone:PO(TID)


Diagnosis: cervical spondylosis
Recurrent hypokalemic paralysis


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