28 yr old male with chest pain

 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

Chief complaints:

A 28 yr old patient resident of suryapet came to the OPD with the Cheifcomplaints of chest pain since 15days,giddiness since 15days neck pain radiating to hand (NL) since 10ams

HOPI

Patient was apparently asymptomatic 15days back then had h/o low bp on and off (?diurnal variation),then had neck pain ,giddiness and weakness

C/o one episode of blood in stools 1 week back subsided with out any medication 

Not associated with any syncopal attacks,fever,Sob 

No h/o hemoptysis,black tarry stools

Past history:

No similar complaints in past

N/K/C/O HTN,DM,TB,CAD,ASTHMA

GENERAL EXAMINATION 

Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

VITALS

Temperature -98F

Pulse rate- 86bpm

Blood pressure-130/70mm hg

Respiratory rate -22cpm

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

PROVISIONAL DIAGNOSIS-ACUTE GASTRITIS,GIDDINESS UNDER EVALUATION,SEVERE DEPRESSION EPISODE

INVESTIGATIONS 

Hb-15.5

Tlc-11,800

Rbc-5.37

PLC-3.16

Blood urea-16

Serum creatinine-0.9

Serum electrolytes 

Na-143

K-3.5

Cl-98

Ca-10.2

Mg-1.9

Rbs-87mg/dl

TREATMENT

1.INJ PAN 40mg PO IV OD

2.SYP SUCRALFATE 10mg PO TID

3.INJ OPTINEURON 1 amp in 100ml NE IV OD

4.TAB ULTRACET 1/2 tab QID