66F HTN 10 YRS ecg incidental IWMI

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.

 A 66 year old  female who is home maker came to  opd for general checkup.

HOPI:

Patient was apparently asymptomatic 10 years back then she was diagnosed as Hypertensive .She is on Amlodipine 2.5 mg  once daily.

Few days back, as a part of general checkup ECG Showed MI changes(silent MI changes).

No C/o chest pain, palpitations,SOB,sweating.

Past history:

Known case of Hypertension since 10 years on amlodipine 2.5 mg.

Not a known case of DM,TB,Epilepsy ,CVA,CAD,Asthma.

Daily Routine:

She is a House wife, she wakes ups at 5AM in the morning, she engages in some spiritual activities (prayers) from 5AM to 7 AM .Then she does her daily household work and she has breakfast at 8:30 AM . She usually has upma ,Idilli,Dosa, for her breakfast. she then gets engaged with household works like washing clothes,preparing lunch and she has lunch at 1PM(Rice item),then she takes rest till 5:00PM .In the evenings she usually has tea then she goes for walking from 5:30PM to 6:30 PM and comes home and prepares dinner and has dinner at around 8:00PM along with her family. she usually has Roti  and rice for  her dinner.She goes to sleeps around  9:30 PM.

Clinical images:






Personal History:

Diet: Mixed

Appetite:Normal

Sleep: adequate 

Bowel and bladder: regular.

No addictions.


Vitals:

BP:140/90 mm hg

PR: 82 bpm

RR :17 cpm

Temp:afebrile.

General examination:

Pallor present,no icterus,clubbing,cyanosis,lymphadenopathy,Edema

Systemic Examination:

Cvs:S1,S2 heard,no murmurs

RS:Bilateral Air entry present,Normal vesicular Breathsounds heard

Per Abdomen:

Soft , Obese,No tender ,No Organomegaly

Cns:No Abnormality detected


Investigations:

Ecg:



X ray:



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