54 yr/F with chest pain

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I have 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

C/O-

Chest pain since 2 -3years

HOPI

Patient was apparently asymptomatic 3 yrs back then she developed chest pain, which dragging type,insidious in onset and gradually progressive in nature associated with Epigastric pain,abdominal bloating and SOB

SOB increased after consuming food

No C/o belching,nausea and vomiting 

C/O pain in B/L knee joints since 3 years

C/O lower backache, wrist joint pain

No C/O Tingling sensation of hand and feet

C/O decreased appetite( patient says she avoids eating)

C/o palpitations, Generalized body pains

C/O polyuria,polyphagiaand polydipsia no c/o burning mitcuration, Giddiness and sweating 

No C/O weight loss/gain,constipation/loose stools, cold/heat intolerance 

PAST HISTORY 

patient is a K/C/O DM2 since 2 years (not on medication since 3 months,unknown medication)

Not a K/C/O HTN,CVA,CAD,thyroid disorder, asthma ,TB and Epilepsy 

PERSONAL HISTORY 

mixed diet 

Decreased appetite since 2 yrs

Regular Bowel movements 

Polyuria

No allergies 

No addictions 

FAMILY HISTORY 

not significant 

Menstrual History _

Menarche-15 yrs

Attained menopause (LMP-10yrs back)

SURGICAL HISTORY-tubectomy 28 yrs back

GENERAL EXAMINATION 

Patient is conscious coherent and cooperative 

No signs of pallor, icterus, cyanosis, clubbing ,lymphadenopathy and pedal edema

Clinical images 

Vitals-

Temp-febrile 

BP-100/60 mm of Hg

PR-82bpm

RR-18cpm

Spo2-97 on room air

GRBS-139

CVS-s1,s2 heard,no murmurs 

Rs-BAE +,NVBS

P/A-SOFT AND NON TENDER

CNS-                 

ONE-         U/L          L/L

               Rt   N              N

               Lt   N              N

Power             U/L       L/L

                Rt    5/5       5/5

                Lt    5/5        5/5

Reflex            Rt            Lt

                 B     2+           2+

                 T      2+           2+

                 S       +              +

                 K       2+          2+

                 A       +              +

                 P       F              F

Investigations 

PROVISIONAL DIAGNOSIS

CHRONIC GASTRITIS? WITH DMT2 SINCE 2 YEARS

TREATMENT 

1.TAB.PAN 40 mg PO/OD

2.SYRUP. SUCRALFATE 10 ml PO/OD

3.GRBS 7 . PROFILE MONITORING 

4.4TH HOURLY VITALS MONITORING