62 yr old man with severe chest pain
Age: 62
Gender: Male
Weight: 46.7 kg
Chief complaints
C/o Chest pain since 2 years ( On & Off ).
Associated with Shortness of breath
Constipation associated with blood in stools.
History of presenting illness:
Patient was apparently asymptomatic 2 years ago
2 years ago, one day he noticed blood with the stool of around 100ml. From that day onwards he says blood comes out with his stool for around 10-15 days continuously then stops for 15 days. This cycle goes on and is still continuing. He feels no itchiness or splinter hemorrhagic pain during defaecation.
In the year 2019, he had an episode of fever which lasted for 7 days. A local Clinician advised a blood test and diabetes was detected. Took medicine for DM for 1.5 years. Is not taking medicine for DM for the past 6 months. DM is under control.
In 2021, one day he started feeling a severe squeezing chest pain, which started from the right sternal border and spread all over the right side, lasting for 5 mins, with a feeling of shortness of breath. This pain gets exaggerated while walking continuously at a stretch(exertional angina). Is relieved with rest. The clinician recommended an angiogram, after which bypass Sx was recommended. The patient started smoking at the age of 35 due to peer pressure and used to smoke 1 pack of bidis/ day. Stopped 3 years ago after being diagnosed with DM due to family pressure. He is nonalcoholic, BP mostly normal or on the lower side. He gave up working as a farmer last year, due to this severe chest pain. Day by day pain is becoming unbearable and more frequent. The patient had to sell his farmland due to financial issues and under mental stress due to financial problems. Now, his son is the only bread earner in his house but his income is not sufficient.
Past history;
K/c/o DM , Hypertension.
No antihypertensives treatment taken.
Personal history:
Married,
Farmer occupation.
Appetite normal.
Bowel and bladder: constipation associated with blood.
Addictions:
Smoking- 1 pack per day for 20 years
No drug use
Examination.
Cardiac examination:
Thrills: No
Murmers - ejection systolic murmer.
Cardiac sounds- S1 , S 2 +
Respiratory examination:
Dyspnea present
BAE +, clear
NVBS,
Trachea central in position
P/A :
No Palpable mass,
No tender abdomen,
Obese,
No liver palpable, no spleen palpable.
CNS:
Patient is conscious, coherent, cooperative.
NAD
Reports:
Complete urine examination:
Liver function tests
Random blood sugar
Patient was on medication
Tab. Ecofit - osr
Tab. Nicorandil - 5mg @night
Tab. Ecosprin AV 150/10 @H/S
Tab. Dapaglifozin 10mg
Tab. Gemer -2mg
Tab Telmisartam + chlordiathialidone+ metaprolol
@ morning
Present medication:
Tab. Pan 40mg/po/do
Tab. Dapagloflozin 10mg OD
Tab. Atorvas 40 mg po/do
Tab. Ecosprin 150mg po/do
SOAP notes: 29/4/22
S:
Chest pain on exertion, blood in stools.
O:
General examination:
Patient is conscious, coherent, cooperative.
Oriented to time , place ,person.
No pallor, icterus, cyanosis, koilonychia, lymphadenopathy, edema.
BP : 120/80
PR: 90bpm
RR: 18 cpm
Cvs examination: S1, S2 heard
Respiratory: BAV present, NVBS.
CNS: NAD
Per Abdomen: NAD
A:
Stable angina
P:
Tab.Pan 40mg /po/od
Tab.Atorvast 40 mg po od
Tab. Ecospirin 150 mg po od
Tab. Dapagliflozin 10mg po od
30/4/22
S:
Chest pain on exertion, blood in stools.
O:
General examination:
Patient is conscious, coherent, cooperative.
Oriented to time , place ,person.
No pallor, icterus, cyanosis, koilonychia, lymphadenopathy, edema.
BP : 120/80
PR: 82bpm
RR: 16 cpm
Cvs examination: S1, S2 heard
Respiratory: BAV present, NVBS.
CNS: NAD
Per Abdomen: NAD
A:
Stable angina
P:
Tab.Pan 40mg /po/od
Tab.Atorvast 40 mg po od
Tab. Ecospirin 150 mg po od
GRBS:
29/4|22
7:00 pm - 118 mg/dl
30/4
10 am - 205mg/dl
1pm - 77 mg/dl
7pm- 181 mg/dl
1/5/22
10pm - 203mg/dl
2am - 243 mg/dl
8am - 119mg/dl
8 pm - 115mg/dl
2/5/22
8am - 106mg/dl
12pm - 171 mg/dl
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