55 Year old female with chest pain and giddiness

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Chief complaint: 

Chest pain and giddiness since 5 50 pm (25/06/23)

History of present illness : 

Patient was apparently asymptomatic till evening on 25/06/23. Then developed chest pain (epigastric region) non radiating. 

Followed by giddiness at around 5:50 pm.

She missed taking tabltets for Daibetes and hypertension on 25/06/23

No h/o of fever , chills, rigors, vomiting, loose stools, pain abdomen. 

Past History : 

K/C/O DM II since 3 years on Tab voglibose 0.3mg , Tab Glimipride 2mg,Tab metformin 500mg 

K/C/O HTN since 3 years on Tab Atenolol 50mg ,Tab Amlodipine 5mg

Family History : 

 no significant family history 

Personal History : 

Physically Active, works as care taker, 

Mixed diet(non vegetarian)

bowel and bladder movements normal

appetite normal

Sleep normal

no known allergies,adductions

 

General examination : 

Patient is conscious, coherent and co-operative.

She is moderately built and moderately nourished.

Pallor - Absent

Icterus - Absent

Cyanosis - Absent 

Clubbing - Absent 

No lymphadenopathy

Pedal edema - Absent

Vitals:

Temperature - 96.2 ° F

Blood Pressure -140/80 mmHg

Pulse Rate -74 bpm

Respiratory Rate - 25 cpm

RBS - 541 gm/dl

Abdominal examination : 

Shape- scaphoid 

Equal movements in all the quadrants.

No visible pulsation and localized swellings, hernial orifices normal 

Liver , spleen not palpable.

 No tenderness . 

CVS:-

Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1and S2 heard

-No murmurs

Respiratory examination:- 

Normal vesicular breath sound heard

 

Investigations: 

 

On 27/6/23

 

Provisional diagnosis:

Uncontrolled sugars with K/C/O HTN since 3 years and K/C/O T2DM since 3 years with AKI 

Treatment: 

INJ HAI S/C TID according to scale 

INJ NPH S/C BD according to scale  

INJ Optineuron 1 Amp in 500 ml NS IV/OD 

Tab Atenolol 50mg PO/ OD 

Tab Amlodipine 5mg 

PO/OD