62 yr old man with severe chest pain

 NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT

Age: 62

Gender: Male

Weight: 46.7 kg

Occupation: Is farming labor by profession(wheat and paddy plantation). In between used to play drums in Yatra 12 years ago. 

PAST HISTORY: 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.

FAMILY HISTORY: His father was a chronic smoker(farming laborer and part-time drummer in Jatra)

Mother alive with no health issues. 

His 2 brothers are also without any health issues

No one in his family reported any heart ailment, DM, HTN or any health issues



REPORT:











Echocardiography report


 Haematology report
Biochemistry report

Urine examination report


Carotid artery duplex ultrasound report


CT scan of chest



ECG at rest

ECG after 6 mins walk


                                                                                

LFT 

                                                                           



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


PREVIOUS MEDICATION:

Aztor 40

Dapaglifozin 10mg

Aspirin

Ecosprine AV 150

Met XL 25

Gemer 2mg

Nicorandil 5mg

Esofit DSR

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


Provisional Diagnosis:

Angiogram: Left main ostial lesion with LAD and Ramus lesion

CABG recommended







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