Case history 10

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 

A 46 yr old male patient presented to the opd with the chief complaint of chest pain, increased sweating, pounding of heart since one month.

History of present illnes: he was apparently asymptomatic 1 month back then he developed chest pain heart burn profuse sweating and palpitations.  Then he went to nearby hospital ,there he was diagnosed with coronary artery disease and was given medication and admitted for 4 days then discharged. They suggested him to get angiogram done. Now after one month he presented to the opd with the similar problems. He noticed that chest pain increased upon climbing stairs and brisk walking ,upon taking rest the pain was relieved.

Past history: he is not a known case of diabetes or hypertension . No history of asthama epilepsy

Personal history: he follows a mixed diet with normal appetite. Bowel and bladder movements are regular.normal sleep cycles. No habits like alcohol consumption or smoking.

Daily routine before the illness: he is worker at construction site,he used to wake up early in the morning has breakfast and goes to work. Then he has lunch in the afternoon,then returns home by 8 has dinner by 9 goes to bed by 10.

Daily routine after the illness: as his occupation was associated with lifting of heavy weights he stopped going to work and stayed at home.he also changed hid diet.reduced salt and sugar intake.also reduced talking fatty foods.

Family history: his father was a known case of cardiac failure and died of stroke.

Drug history: no allergy to any known drugs .he was on medication for chest pain

Vitals: temperature: afebrile. BP : 130/80mmhg pulse rate: 86 BPM. Respiratory rate: 20cpm  spo2: 99, random blood sugar: 78mg/dl

Systemic examination: 

Cvs: bilaterally symmetric chest wall .no precordial bulge .no thrills and no murmurs. s1 and s2 heard

Respiratory system: no dyspnea,no wheeze

Position of trachea- central, no adventious sound heard

CNS: patient is normal and concious .reflexs are normal

Investigations to be done: angiogram 

Provisional diagnosis: coronary artery disease.

Differential diagnosis: acute angina pain, pleural effusion, pericardial effusion. 

Treatment: fluid and salt restriction,pan40(od),ecosprin(od),alprazolam(bd),nitrocontin(bd)