A 46 yr old male with chest pain-
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A 46 yr old male patient presented to the opd with the chief complaint of chest pain, increased sweating and pounding of heart since one month.
History of present illness: He was apparently normal 1 month back then he developed chest pain profuse sweating and palpitations.
Then he went to nearby hospital .There he was diagnosed with coronary artery disease , 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 and epilepsy. Gastric trouble since 5-6 years.
General examination-
No pallor
No cyanosis
No lymphadenopathy
No icterus
No clubbing
No pedal edema
Personal history: diet- mixed
Appetite- normal
Bowel and bladder movements - regular
sleep cycles- normal
Addictions- no habits like alcohol consumption or tobacco smoking.
Daily routine before the illness: he is worker at construction site.he generally wakes up early in the morning has breakfast and goes to work followed by lunch in the afternoon. Then returns home by 8 have 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 his diet.reduced salt and sugar intake.also reduced taking 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
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 sounds 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 restrictions, pan 40(od), ecosprin(od), alprazolam(od),nitrocontin(bd)
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