MAJED ABDULLAH M ALHUZALI

Personal data, Chief complain:

Saleh is a 54-year-old Saudi male smoker known case of type II diabetes more than
15 years, and hypertension for 8 years. He came to the ER on the 20th of
December complaining of chest pain and pounding sensation in the chest for
two days.  

HPI: 
He was in his usual state of health until approximately two days ago when he
started to have a gradual onset of retrosternal chest pain squeezing in nature just
when he woke up that morning, radiating to the left shoulder and lasted for less
than 20 min. He scaled the severity of this pain as 4 out of 10. He ignored it and
went to pray at the mosque, that day, the pain subsided. On the next day, the pain
started at rest, but this time with palpitation. On scaling this episode, salah
mentioned it is 9 out of 10 and lasted for more than 30 minutes. The palpitation
was described as irregular, fast, continuous. Not bound to the neck, not related to
lying down, no loss of consciousness during the episode. He tried to take a deep
breath, but this deep breath could not terminate the palpitation. He did not notice
any alleviating or exacerbating factors as he came to the ER right away. 

The patient was vitally stable at the time of taking the history

HR: 92, BP: 118/79

Associated symptoms:
+ve: CVS: chest pain, palpitation, dizziness, dyspnea, orthopnea, cold extremities.

-ve: CVS: PND, ankle swelling, easy fatigability, syncope.

Constitutional symptoms:
There was NO fever NO night sweating, NO loss of weight NO loss of appetite.

Systemic review: 
 RS: dyspnea, No cough, sputum, hemoptysis, horsiness.
MAJED ABDULLAH M ALHUZALI

 GIT: abdominal pain, heartburn, nausea, vomiting, No diarrhea, constipation,

hematemesis.

 CNS: No loss of consciousness, no vertigo, no headache, and no convulsion

 Hematology: No bone pain, no skin rash, and no lymph node swelling.

 Endocrine: No neck swelling, no appetite change, no weight change or

heat/cold intolerance.

 Urinary: No Foamy urine, no hematuria or dysuria.

The rest systems were not remarkable.

Past-medical history:
The patient is a known type 2 diabetes case for over 15 years, controlled by oral
metformin 500 mg per day. He also has HTN for 8 years, controlled by captopril.
The patient is complaint to his medication. Duodenal ulcer was diagnosed 2 years
ago at KAUH controlled by omeprazole. No hx of past blood transfusions,
received his vaccines, no allergy to specific irritants, and no pets at home.

Past-surgical history:
The patient had only one gastric endoscopy 2 years ago at KAUH with no
complications.

Social history:
He is smoker for 40-year 1 pack/ day, married with 7 children with no known
history of travel or contact with sick patients, no hx of illicit drug use,  

Family history:
He has a family history of DM and HTN, He has a history of consanguinity
marriage. No family history of cancer or sudden death or any similar episodes.

Summary:
A 54-year-old male smoker known case of diabetes type II for over 15 years and
hypertension for 8 years, came to the ER on the 20th of December complaining of
MAJED ABDULLAH M ALHUZALI

chest pain and palpitation for 2 days. The chest pain was retrosternal and radiated
to Left shoulder associated with palpitation, dizziness, dyspnea, orthopnea, cold
extremities, abdominal pain, heartburn, nausea, vomiting. No history of PND,
syncopal attack, no cough or diarrhea.

DDX:

 MI chest pain radiate to the left arm.

 Unstable angina

 SVT

 Anemia

 Hyperthyroidism

Investigations:

 ECG

 CBC (to exclude any infections or Anemia)

 Thyroid panel (to exclude hyperthyroidism)

 CK-MB & Troponin (to exclude Cardiac muscle injury – ACS)

 Chest x-ray (to look for cardiomegaly or aortic abnormality)

 Echo (to look for EF% and valvular deformities)

 Exercise stress test

 Coronary angiography (to Exclude ACS)