The Master clinician assignment

The Master Clinician assignment

Group B

Nour Bizri, Jamile Zeidan, Sophia El Zahabi, Jhonny Fawaz, Michel Salem

Case Report

Faculty of Medicine,

Saint George University of Beirut

Submitted to:

Dr. Nelly Klayme

January 25, 2023

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Patient Information

Date of visit: January 9, 2023

Name: Mrs. N. Haddad

Patient information: widow who has 3 children and 6 grandchildren.

Sex: female

Date of Birth: 1954

Previous visits: November 23 with Dr. Hala for sinusitis.

Chief complaint

Mrs. Haddad is a 69-year-old female, smoker, known to have well treated

hypertension, dyslipidemia, and osteoarthritis, presenting for ongoing sinusitis. The

sinusitis has been going on for 2 months and did not get better despite the use of

prescribed nasal steroids, antihistamines, and antibiotics. She had cervical disc

surgery 2 years ago and is doing well. She fell around the time her sinusitis started.

She also reports having a brief episode of severe chest pain (7/10) for 30 minutes

which radiated to her neck 2 weeks ago. She denies any recurrence ever since. She

also denies alcohol and drug use.

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History

Past medical history:

- hypertension
- osteoarthritis in the knees
- sinusitis
- neuropathy of the brain
- dyslipidemia
- ‫أعصاب‬

Past surgical history:

Cervical disc surgery (in 2021)

Medications:

- Aerius —> for sinusitis

- Singulair 10 mg (anti leukotriene) —> for sinusitis
- Shifted to micardis / 12.5 (ace inhibitor + diuretic) after previously using
amlodipine —> for hypertension
- Aspirin 81 mg (for neuropathy)
- Rosuvastatin 20 mg (for cholesterol)
- Cipralex 10 mg (for ‫)أعصاب‬

Allergies: has allergies taking anti histamine

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Family history: didn’t note any.

Social history:

-widow
-has 3 children
-doesn’t work
-smoker
-no drugs
-doesn’t drink alcohol