16 year old female with chest pain and sob



 This is online E log book to discuss our patient’s de-identified health data shared after taking his/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 patients 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 comment box is welcome .



I’ve 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.

Case : 
16 year old female with chest pain and sob 

Chief complaints: 
Pt c/o chest pain and sob since 20 days 

HOPI: 
Pt was apparently asymptomatic 2 months back 
Then she developed  headache which was sudden in onset and gradual in progression for which she checked with an opthamologist and was prescribed with spectacles and was relieved 
She then had chest pain which was also sudden in onset gradual in progression on the left side pricking type radiating to left arm associated with shortness of breath since 20 days 
Not associated with palpitations, sweating, syncopal attacks 
No c/o orthopnea, PND
She had cold 15 days back for which she used tab levocitrazine which got resolved 
But the chest pain still continued
No h/o fever , loose stools, vomitings , burning micturition 

Past history: 
Not a k/c/o DM, HTN, asthma, epilepsy, thyroid disorders 

Personal history: 
Diet : mixed 
Appetite: normal 
Bowel and bladder habits: regular 
Sleep: adequate 
No addictions 

Family history: insignificant 

Menstrual history: 
Age of menarche: 13 years 
Irregular cycles 
7-9 days of bleeding 
Lmp : 1-9-2022 

General examination: 
Pt is conscious coherent and cooperative 
Well oriented to time, place and person 
Moderately built and nourished 
Pallor icterus cyanosis lymphadenopathy edema are absent 
Vitals: 
Temp : 98.6
BP : 120/80 mm Hg 
PR: 78bpm 
Spo2: 99% 

        

Systemic examination: 
CVS: s1, s2 heard 
No murmurs 
RS: BAE+ NVBS heard 
Per abdomen: 
Soft , non tender 
No tenderness, guarding, rigidity 
Bowel sounds heard 
CNS: NAD 

Investigations: 
Hemogram: 



ESR: 

    



LFT: 

    


RFT: 

    


Random blood sugar: 

      



Blood grouping and typing: 

      



ECG: 


     

 
Chest X-ray: 
      
     

   


2D ECHO:

     
      



Provisional diagnosis: 

? Acute gastroenteritis 
 ? WPW syndrome 

Treatment:

1) inj pan 40mg Iv OD 
2) inj optineuron 1 amp in 100 ml ND / Iv / OD 
3) sup mucaine gel 10ml po TID
4) Iv fluids 1 DNS @75 ml: hr 
5) Tab Beplex forte po od for 







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