Patient Medical Case Report
Patient Medical Case Report
1. Patient Information
Demographics
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Name: John Doe
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Age: 45
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Gender: Male
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Ethnicity: Caucasian
Contact Information
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Address: 123 Elm Street, Springfield
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Phone: (555) 123-4567
2. Presenting Complaint
The patient presented to the clinic with complaints of chest pain radiating to the left arm and shortness of breath.
3. History of Presenting Illness
The symptoms started suddenly while the patient was walking upstairs. The chest pain was described as a heavy and pressing sensation. The patient rated the pain as 8/10 in intensity and noted associated sweating and nausea. No history of trauma was reported.
A. Past Medical History
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Hypertension, diagnosed 10 years ago
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Type 2 Diabetes Mellitus, diagnosed 5 years ago
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Hyperlipidemia
B. Family History
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Father died of myocardial infarction at age 60
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Mother has hypertension
C. Social History
The patient is a non-smoker and consumes alcohol occasionally. He is employed as an accountant and lives with his spouse and two children. There is no history of illicit drug use.
4. Review of Systems
|
System |
Symptoms |
|---|---|
|
Cardiovascular |
Chest pain, palpitations |
|
Respiratory |
Shortness of breath |
|
Gastrointestinal |
Nausea |
|
Others |
No fever, no weight loss |
A. Medications
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Lisinopril 10 mg once daily
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Metformin 500 mg twice daily
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Atorvastatin 20 mg once daily
B. Allergies
No known drug allergies.
5. Physical Examination
A. Vital Signs
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Blood Pressure: 140/90 mmHg
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Heart Rate: 95 beats per minute
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Respiratory Rate: 20 breaths per minute
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Temperature: 98.6°F (37°C)
B. General Appearance
The patient appears anxious and diaphoretic but is alert and oriented. He is in moderate distress due to chest pain.
C. Cardiovascular Examination
The heart sounds are regular with no murmurs, gallops, or rubs detected. Peripheral pulses are equal and symmetrical.
D. Respiratory Examination
Bilateral breath sounds are clear on auscultation. There are no wheezes or crackles.
6. Investigations
A. Laboratory Tests
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Complete Blood Count (CBC): Within normal limits
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Electrolytes: Sodium: 140 mmol/L, Potassium: 4.5 mmol/L
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Fasting Blood Sugar: 130 mg/dL
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HbA1c: 7.2%
B. Imaging Studies
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Chest X-ray: No acute abnormalities
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ECG: ST-segment elevation in leads II, III, and aVF
7. Diagnosis
The clinical presentation and ECG findings suggest an acute inferior myocardial infarction.
8. Treatment
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Aspirin 325 mg
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Clopidogrel 75 mg daily
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Beta-blocker (Metoprolol)
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Admission to coronary care unit for further management
9. Follow-Up
The patient will be monitored for clinical response and potential complications in the coronary care unit. Follow-up appointments will be scheduled to reassess cardiovascular health and manage risk factors, including diabetes and hypertension management.
