myocardial infarction case presentation

Views:
 
Category: Education
     
 

Presentation Description

case presentation history, examination

Comments

By: ahmedhafez2030 (43 month(s) ago)

ربنا يبارك فيك د جواد

Presentation Transcript

CASE PRESENTATION : 

CASE PRESENTATION DR. jawed

BIODATA : 

BIODATA Age: 65 years Sex: Male 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. Vesicular breathing No crepits or ronchi

Gastrointestinal system : 

Gastrointestinal system No hepatosplenomegaly Central Nervous System Normal sensory and motor exam Fundoscopy: 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 Aortic dissection