61 year old farmer (long distance)
This is an 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 patient's clinical problems with collective current best evidence based inputs
61 year old farmer by occupation came with chief complaints of chest tightness
Diagnosis- LEFT SHOULDER PAIN UNDER EVALUATION WITH LEFT MERALGIA PARASTHETICA WITH H/O HTN
Pt was apparently asymptomatic 10 months back and had developed sudden onset dizziness and chest tightness. Whenever he consumes spicy or heavy foods, he experiences dragging type of pain in the left infra-axillary area of chest
When he applies pressure on left side of chest(infra axillary area for pain relief), there is relief, belching(+)
Difficulty in passing stools, no blood or mucus in stools
Right thigh- c/o sensation of insect crawling over thigh followed by burning sensation
K/c/o HTN since 2 years, on T.Amlodipine/Atenolol (5/50) po/od
Pt is c c c
Bp-150/80mmHg
Pr-82bpm
Rr-16cpm
Temp-afebrile
Sleep- normal
Appetite normal
Bowel and bladder-regular
No addictions
CVS- S1 S2 heard
Rs- BAE+ve
P/a- soft, non tender
CNS-, NFND
Provisional Diagnosis- Left shoulder pain under evaluation
Department of Orthopaedics referral taken i/v/o Decreased Translucency of L humerus on CXR.
Advised 1. Left Shoulder X-ray AP and axillary view
2. Xray pelvis with both hips- AP view
3.continue short wave diathermy
4. Shoulder girdle exercises
5.T. GABAPIN 10MG PO/HS X 15 DAYS
6. T.MYORIL 4MG PO/BD X 5 DAYS
Soap notes 15/122
61 year old male with Left shoulder pain
S- shoulder pain reduced
O-
Bp- 180/90 mmhg
Pr- 84 BPM
RR- 16cpm
CVS- S1 S2 heard
RS- BAE +
P/A- SOFT non tender
CNS- NFND
A- L shoulder pain under evaluation with L Meralgia Parasthetica with h/o HTN
P-
T. PANTOP 40MG PO/OD
T. ULTRACET ½ PO/QID
T . DOLO 650MG PO/TID
T. AMLONG 5MG PO/OD
T. GABAPIN 10MG PO/HS X 15 DAYS
T.MYORIL 4MG PO/BD X 5 DAYS
Shoulder girdle exercises
Continue short wave diathermy
61 year old male with Left infra axillary p pain
S- shoulder pain reduced
O-
Bp- 180/90 mmhg
Pr- 84 BPM
RR- 16cpm
CVS- S1 S2 heard
RS- BAE +
P/A- SOFT non tender
CNS- NFND
A- L infra-axillary pain under evaluation (Pain at left Infra axillary area) with Left Maralgia Parasthetica with h/o HTN
P-
T. PANTOP 40MG PO/OD
T . DOLO 650MG PO/TID
T. AMLONG 5MG PO/OD
T. GABAPIN 10MG PO/HS X 15 DAYS
T.MYORIL 4MG PO/BD X 5 DAYS
Shoulder girdle exercises
Continue short wave diathermy
4th hrly bp monitoring
posted by Pranati. V @ January 13, 2022
<< Home