A Case Of Chest Pain

A 50 year old obese shopkeeper presents to your clinic with central chest pain on walking back to his shop after lunch. The pain occurred twice in the last 10 days, lasted for 10 - 15 minutes each time and subsided after the shopkeeper reached his shop and sat down. Both times when the shopkeeper reached his shop he was bathed in sweat.

1. What are the two most likely diagnosis?
2. How will you evaluate his problem?
3. How will you manage this problem?

Question Solved:



1. What are the two most likely diagnosis?

Answer:
1. Angina Pectoris
2. Myocardial Infarction

2. How will you evaluate his problem?

Answer: This patient would need following investigations to evaluate his problem:

• Blood Pressure measurements ( the patient may have underlying hypertension)
• Weight and BMI 
• ECG ( look for ST segment depression, t wave inversion)
• Stress test
• Chest X ray
• Echocardiogram
• Cardiac enzymes ( increased levels indicate MI)
• Lipid profile
• Fasting blood glucose
• Coronary angiography

3. How will you manage this problem?

Answer: the following steps are important i managing this patient:

• Avoid high fat diet and encourage weight loss.
• Avoid large meals and severe exertion
• Hospitalization for observation and to prevent a heart attack
• Sub lingual nitrates in case of another episode of chest pain.
• Start low dose aspirin (75 mg) once daily.
• Cardioselective beta blockers like atenolol (50 mg once daily) or metoprolol (100 mg in one or two divided doses). these can be adjusted depending upon patient's response to treatment and result of investigations. 
• May need a referral to a cardiologist for coronary angioplasty