CASE PRESENTATION : CASE PRESENTATION DR. jawed BIODATA : BIODATA Age: 65 years
Address: Presenting complain : Presenting complain Chest Pain since 3 days. History of presenting illness : History of presenting illness 65 years old male presented in Emergency room with history of retrosternal chest pain for the last 3 days, sudden onset, severe, burning, at around 3 am awoke him from sleep, continuous for 4 hours, radiating to left shoulder, not relieved by rest associated with nausea. History of Presenting illness : History of Presenting illness Pain not increase by inspiration or changing in position.
No history of shortness of breath, no palpitation, no history of fever, no cough or hemoptysis, no history of fall down or any trauma. Slide 6: He went to near by clinic, where he was given oral medication, after that his pain decrease in intensity, but not completely relieved, after 3 days of treatment he came to our hospital for further assessment. Review of systems : Review of systems General: No loss of weight No change in appetite No malaise or weakness No sleep disturbanceGIT: No abdominal pain No Diarrhea or constipation No haematamesis or melana Review of systems : Review of systems Respiratory system: No difficulty in breathing No coughGenito urinary: No burning micturation No haematuriaCNS: No fits No weakness PAST HISTORY : PAST HISTORY No history of hypertension or diabetes. PERSONAL HISTORY : PERSONAL HISTORY Non smoker
Bowel and dietary habits normal. Summary : Summary 41 years old male presented with history of retrosternal chest pain for the last 3 days, severe continuous for 4 hours then decrease in intensity associated with nausea. Examination : Examination male with average height and built lying on bed conscious and oriented.
Pulse: 106 b/ min regular
BP: 130/ 80 mmHg
Temperature: 37.0 Examination : Examination No pallor or jaundice
No clubbing or splinter hemorrhages
JVP not raised
No carotid bruit
No neck swelling
No palpable lymph nodes Examination : Examination Pulses equally palpable on both sides, normal volume
No radio femoral delay
No lower limb or sacral edema
No rashes Cardiovascular examination : Cardiovascular examination Apex beat in 5th intercostal space at mid clavicular line, non sustained.
No thrill or heave
S1 and S2 with normal intensity.
No gallop or murmur Respiratory system : Respiratory system Chest bilaterally symmetrical moving with respiration.
No crepits or ronchi Gastrointestinal system : Gastrointestinal system No hepatosplenomegaly
Central Nervous System
Normal sensory and motor exam
Normal fundus exam SUMMARY : SUMMARY 65 years old male diabetic, HTN with history of retrosternal chest pain since 4 hours severe with sweating had normal pulse and blood pressure and no significant exam finding. Differential diagnosis : Differential diagnosis Myocardial infarction