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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comments..Date of admission: 17- 12- 2021
A 45 year old man , building construction worker by occupation came to OPD with chief complaints of chest pain since one month.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic one year back, he used to wake up 6 in the morning for work, completing breakfast(rice curry) and reaching to contruction site by 9'0 clock. He used to carry heavy bags of sand and stone and sometimes carrying to upper floors. By completing work by 6 in the evening, reaching home, having tea biscuits for snacks and sleeping by 9'0 clock followed by dinner(rice, roti and veggies)
One fine day, patient complains of high grade fever which was sudden in onset with head ache. He went to hospital, where he was diagnosed with type 2 diabetic mellitus.
Intially, his sugar level was 300, he used medication for one month. After the sugar levels were normal, patient stopped using the medications since then.
In november, patient was heading to work in bicycle, he experiences pain in the chest region which was sudden in onset. He stopped riding the bicycle, gasped for breath, then he again started to go, where he again experiences severe pain. He went to local hospital, where he was advised some medications for acidity, and asked to rest for two days.
After 2 days, patient went to work, where he carried heavy weighted sand bag to upstairs. Theñ, he experiences severe throbbing pain in the left side of chest. He was given medications for pain relief.
Since one month, patient complains of chest pain which is pressing, squeezing type, strangling, constricting like a band across the chest with profuse sweating and palpitations. It aggravates on exertion. The pain usually last for 10-15mins.
There is no history of fever, vomiting and shortness of breath.
There is no history of radiating pain to the left hand, neck, jaw and teeth.
PAST HISTORY:
patient is a known case of diabetes mellitus since 1 year with on and off medication. Patient complains of gastric acidity since 2years.
There is no history of epilepsy, asthma and COPD.
There is no history of any surgeries.
FAMILY HISTORY:
There is no history of similar complaints in the family. There is no history of sudden deaths .
PERSONAL HISTORY:
Apetite: Normal
Diet :mixed
Sleep: inadequate due to pain
Bowel and bladder habits: regular
Addictions: non smoker but consumes alcohol occasionally 250ml ( beer)
GENERAL EXAMINATION:
patient was conscious, coherent , cooperative and well oriented to time, place and person.
He is heavily built and well nourished
No pallor
No cyanosis
No icterus
No history of generalised lymphadenopathy.
VITALS:
Temperature: afebrile
Respiratory rate: 18cpm
Pulse rate: 70bpm
Blood pressure: 120/70mm Hg
GRBS: 290
Spo2 at room temperature:
SYSTEMIC EXAMINATION:
Cvs examination:
Inspection :
No precordial bulge
No scars sinuses and engorged veins
No visible pulsation
Palpation:
apical impulse : heard in fifth inter coastal space
Auscultation:
S1 and S2 heard
No murmurs.
CNS examination:
- Higher mental functions-normal
- Cranial nerves- intact
- Sensory system- normal
- Motor system- normal
- Meningeal signs- absent
- Cerebellar signs- absent
Respiratory system examination:
Inspection of upper respiratory system-
oral cavity- normal
Nose- normal
Pharynx- normal
Lower Respiratory Tract:
Inspection:
trachea: central
Symmetry of chest : symmetrical
Movement: B/L symmetrical expansion of chest respiration
No scars, engorged veins or sinuses.
Palpation:
All inspectory findings are confirmed by palpation.
Trachea: central - confirmed by three finger test.
Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.
No chest wall tenderness
Vocal fremitus- normall
Percussion :
done in sitting position
Resonant
Auscultation:
Vesicular breath sounds heard
Bilateral air entry present
No added sounds
*Abdominal examination:
Inspection:
Shape : elliptical
Quadrants of abdomen moving in accordance with respiration.
No scars sinuses or engorged veins
Palpation:
No tenderness
No organomegaly
Percussion:
tympanic
Auscultation:
Normal
No organomegaly , no tenderness
PROVISIONAL DIAGNOSIS:
Coronary artery disease
INVESTIGATIONS:
ECG:
Colour doppler 2D echo:
USG:
FINAL DIAGNOSIS:
CORONARY ARTERY DISEASE WITH HEART FAILURE WITH REDUCED EJECTION FRACTION. ( EJECTION FRACTION 40%)
TREATMENT:
1. Fluid restriction < 1.5g/day and salt restriction< 2g/day.
2. T. CARDALE METO 2.5/ 4.5
3. TAB. PAN 40mg
4. TAB. ECOSPIRIN GOLD 20 PO
/ OD
5. TAB . ALPRAZOLAM O.25mg
6. Tab. NITIROCONTIN 2.6mg/ B.d
7. TAB . METFORMIN 500mg /B.d
How can diabetes cause coronary artery disease?
Diabetes cause macrovasculature changes thereby affecting major blood vessels like coronary arteries by formation of plaque there by narowing the arteries reducing the supply of blood by a process know as Atherosclerosis
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