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


B.SHRADHA
Rollno :- 10
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.
A 70 year old female came to casuality on 05-01-2021 with 
Cheif complaints:-
*fever since 1 day. 
*Left sided chest pain since yesterday night and vomiting since today( 5 Jan) morning (1 episode) at 4 am.
History of presenting illness:-
She was apparently asymptomatic 1 day back and then she developed fever, lowgrade, continuos relieved on taking medication. Not associated with chills and rigors
Left sided chest pain  Radiating, pricking type of sensation to the left hand, associated with sweating, heaviness to the chest and chest tightness present.
Vomitings in the morning at 4am had non projectile, non bilious, contains food particles and non foul smelling.

Past history:
In 2007 she had similar complains PTCA (LCX territory)---> triple vessel disease LCX, RCA CABG done. 
In 2017 similar complaints admitted in NIMS, conservatively treated.
K/c/o diabetes and hypertension since 15 years.
Using vildaglitan 50 mg and metformin 500mg and telma 40 mg.
General Examination:

Patient  is conscious , cooperative, well oriented to time place and person.

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema





Vitals:

PR- 85 bpm
BP- 130/80 mmHg
RR- 14 cpm
SpO2- 100% at RA
Systemic examination:-
CVS:-
Inspection- Normal.

Palpation- Normal.

Auscultation:-
 SI, S2 heard. No murmurs 

RS: BAE + , NVBS

ABDOMEN: Soft and non tender

CNS: NAFD
Investigations:
10-01-2021

TROP - 1 is positive.
ECG:-
05-01-2021
06-01-2021
07-01-2021


Diagnosis: 
DKA with anteroinferior wall MI (NSTEMI).

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

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