52M with chest pain, bleeding p/r

 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. 

PATIENT HISTORY: Pt is a 52 yr old male working as a shoe seller. Needs to sit in a chair or sometimes on the floor for a long time.

21 years ago, got involved in an accident (his cycle collided with a motorcycle). He fell down and had a hairline fracture in his hip jt. He got treated by a local Dr and with medicines, bed rest, and physiotherapy he got cured. After that no more pain. But he c/o after recovery he walks a bit inclined towards the left side), no weakness in legs as such.

Within a month of this incident, he started c/o constipation (2 days no defecation at all, on third-day defecation in little quantity, stool not hard), abd. bloating, pain around the umbilicus, and flatulence. Consulted many Dr. but medicines did not yield satisfactory results.

On Mar 2022, one day after eating a rice meal at 10 am like usual, within 30 mins started c/o s severe squeezing kind of pain beginning on the left side of the chest and radiating towards the shoulder and armpit and towards neck and jaw. He felt lightheaded. He poured cold water over his head and neck which reduced the pain slightly. He was rushed to the hospital and was told he had had a heart attack. Discharged after 6 days. 

After returning home, went to see a Cardiologist who asked him to do Coronary angiography. Was given the Ecosprin tab.

On Sep one episode of bleeding P/R. Dr recommended doing a colonoscopy and endoscopy, but pt could not afford them at that time. 

No c/o SOB, no c/o orthopnea, no c/o angina on exertion

Pt started smoking at the age of 15 yrs. Smokes bidis (1-2/day) after the March event stopped smoking.

Not a k/c/o DM/HTN.

On medication - Aspirin o.d, Pantoprazole +Domeperidone b.d

CHIEF COMPLAINTS AND PT REQ.: Sometimes slight non-radiating chest pain on left side lasting for 1-2 hrs (1-2 times, 3-4 days per wk)

 c/o slight lower back pain (10-15 mins, 3-4 days/ wk). The pain intensifies while getting up from a sleeping position or chair. 

Constipation, abd bloating, and pain around the umbilicus

This month 3 episodes of bleeding P/R (painless heavy bleeding while defecating)

FAMILY HISTORY : No complaint of any health issues



REPORTS: 






























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