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Jatin Sharma
Roll no. 46
46 YEAR OLD MALE WITH ANGINA AND TYPE 2 DM
A 46 year old male labour by occupation resident of Kolkata presented to the OPD on 17th December 2021 with chief complaint of pain in chest on walking fast.
History of presenting illness
- Patient was apparently asymptomatic one month back then he developed sudden chest pain while going down through stairs which was of squeezing type, aggravating on walking, not relieving on rest, radiating to upper back with palpitation and sweating for this he went to a hospital and got admitted.
- In hospital the patient was diagnosed with Angina and received medication for the same and discharged after 4 days.
- Since then patient is experiencing chest pain on walking fast which is of squeezing type and aggravate on continuous walking and exertion. It subsides on taking rest and medicine in approx 15-20 min. for this complaint he presented to our hospital.
- No history of SOB, nausea, vomiting and regurgitation of food.
Past history
- Similar complaint of chest pain since one month for which he is on medication.
- Known case of type 2 diabetes mellitus since 3 months taking no medicine.
- Not a known case of TB, asthma, HTN, epilepsy.
Personal history
- Appetite normal
- Diet mixed
- Sleep is adequate
- Bowel and bladder movements are regular
- He has a habit of tobacco chewing since 20 years
Drug/Treatment history
- Tab. clopidogrel and aspirin
- Tab. nitroglycerin
- Tab. alprazolam
- Tab. Ramipril and metoprolol
Taking all 4 medicines everyday since last one month
Family history
-No history of diabetes, hypertension, heart disease, Cancer
General examination
- Patient was examined in a well lit room, after taking informed consent.
- Conscious, coherent, cooperative,well nourished,well oriented to time,place, person
Vitals
- Temp-afebrile
- BP-110/80 mmhg
- PR-86 bpm
- RR-15 cpm
- No Pallor, Icterus, Cyanosis, Clubbing, Edema, Lymphadenopathy
Systemic examination
CVS
- S1, S2 heard
- No murmur
Respiratory system
-Central position of trachea
-Vesicular breath sounds
-No wheeze,no dyspnea
Abdominal examination
-No tenderness
-No palpable masses
-bowel sounds normal
Central nervous system examination
-Level of consciousness–alert
-Speech--normal
-sensory system--normal
-Reflexes normal
Investigations
Done on 18/12/21
Done on 18/12/21
Done on 18/12/21
Done on 10/11/21
Clinical pictures
Taken on 17/12/21
Summery
- A 46 year old male patient came to the OPD with chief complaint of chest pain on walking fast and exertion. He is a known case of type 2 DM.
Provisional Diagnosis
- Coronary artery disease - Angina with type 2 DM
