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CASE PRESENTATION
DR SHIVANI SAHU
DR MAHENDRA CHAUHAN
• 24 Y Female, Lalita Raut, a Resident of CHHINDWARA, MP came to
Lata Mangeshkar Hospital, Digdoh Hills, Nagpur with
• C/o Chest pain since 2 months.
• C/o Palpitations since 2 months.
HISTORY OF PRESENTING ILLNESS
• Pt was apparently all right 2 months ago when she developed Chest
pain that was insidious in onset, throbbing in character, did not get
alleviated by taking rest, did not get aggrevated by doing physical
work, did not radiate to other sites in the body, had no exacerbating
factors and was mild in intensity. (Pain did not hamper day to day
activities of patient).
• Patient also c/o Palpitations that started 2 months ago, were sudden
in onset, had no aggravating or relieving factors and was mild in
intensity.
• Pt is a k/c/o HTN since 2 months on regular medication. (TAB METXL 50 MG
PO OD)
• Pt gives No H/o Trauma to Chest.
• No H/o Fever.
• No H/o Radiation of pain to Left Arm.
• No H/o Pedal edema.
• No H/o Giddiness.
• No H/o Pain in legs on Exercise.
• No H/o Pain in Abdomen.
• No H/o similar complaints in the past.
• No H/o previous Major Surgery.
• No H/o TB/BA/DM
GYNAECOLOGICAL HISTORY
• Pt is unmarried, Nulligravida, LMP: 6 months ago.
• No H/o white discharge pv
• No H/o sudden breakthrough bleeding pv.
• No H/o itching pv.
PERSONAL HISTORY
• Pt takes Mixed diet.
• Pt has regular bowel/ bladder movement.
• Pt has regular sleep pattern. Pt is not awaken in sleep by palpitations.
• Pt claims to have no addictions.
GENERAL EXAMINATION
• P: 100/min, Regular, bounding pulse taken in Right Radial artery in
Supine position.
• BP: 150/90 mm Hg, taken in Right Forearm, Supine position by a
Mercury Sphygmomanometer.
• Pallor: present. Icterus: Absent.
• No Cervical lymphadenopathy/ Supraclavicular lymphadenopathy.
SYSTEMIC EXAM
• CVS: S1, S2 Normal.
• CNS: Conscious, Oriented
• RS: AEBE
PER ABDOMEN EXAM
• Inspection: Abdomen is soft, Non tender, No e/o Visible lump or
swelling
• Palpation: done in well lit room in the presence of a female attendant.
• No e/o Palpation lump, dilated veins.

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Presentation.pptx

  • 1. CASE PRESENTATION DR SHIVANI SAHU DR MAHENDRA CHAUHAN
  • 2. • 24 Y Female, Lalita Raut, a Resident of CHHINDWARA, MP came to Lata Mangeshkar Hospital, Digdoh Hills, Nagpur with • C/o Chest pain since 2 months. • C/o Palpitations since 2 months.
  • 3. HISTORY OF PRESENTING ILLNESS • Pt was apparently all right 2 months ago when she developed Chest pain that was insidious in onset, throbbing in character, did not get alleviated by taking rest, did not get aggrevated by doing physical work, did not radiate to other sites in the body, had no exacerbating factors and was mild in intensity. (Pain did not hamper day to day activities of patient). • Patient also c/o Palpitations that started 2 months ago, were sudden in onset, had no aggravating or relieving factors and was mild in intensity.
  • 4. • Pt is a k/c/o HTN since 2 months on regular medication. (TAB METXL 50 MG PO OD) • Pt gives No H/o Trauma to Chest. • No H/o Fever. • No H/o Radiation of pain to Left Arm. • No H/o Pedal edema. • No H/o Giddiness. • No H/o Pain in legs on Exercise. • No H/o Pain in Abdomen. • No H/o similar complaints in the past.
  • 5. • No H/o previous Major Surgery. • No H/o TB/BA/DM
  • 6. GYNAECOLOGICAL HISTORY • Pt is unmarried, Nulligravida, LMP: 6 months ago. • No H/o white discharge pv • No H/o sudden breakthrough bleeding pv. • No H/o itching pv.
  • 7. PERSONAL HISTORY • Pt takes Mixed diet. • Pt has regular bowel/ bladder movement. • Pt has regular sleep pattern. Pt is not awaken in sleep by palpitations. • Pt claims to have no addictions.
  • 8. GENERAL EXAMINATION • P: 100/min, Regular, bounding pulse taken in Right Radial artery in Supine position. • BP: 150/90 mm Hg, taken in Right Forearm, Supine position by a Mercury Sphygmomanometer. • Pallor: present. Icterus: Absent. • No Cervical lymphadenopathy/ Supraclavicular lymphadenopathy.
  • 9. SYSTEMIC EXAM • CVS: S1, S2 Normal. • CNS: Conscious, Oriented • RS: AEBE
  • 10. PER ABDOMEN EXAM • Inspection: Abdomen is soft, Non tender, No e/o Visible lump or swelling • Palpation: done in well lit room in the presence of a female attendant. • No e/o Palpation lump, dilated veins.