22M with chief complaints of Chest pain since 1 month

This is an online e log book to discuss our patient's deidentified health data shared after taking his/her guardian's signed informed consent. Here we discuss our individual patient's problems with collector's current best evident input.This e blog also reflects my patient centered online learning portfolio and your valuable inputs in the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment

 A 22 yr old male came to the OPD with 

Chief complaint: chest pain since 1 month

HOPI: Patient was apparently asymptomatic 1 month ago and then developed chest pain which was sudden in onset, gradually progressive, intermittent, of aching type, with no aggravating or relieving factors. It is non- radiating and not associated with any other pain. Pain is associated with SOB since 1 month which is aggravated on excercising and relieved on taking rest.

Negative history: No history of trauma, headache, neck pain, nausea, vomiting, fever, pain in abdomen

Past history: Not a known case of DM, HTN, Tb, Asthma, Thyroid, CAD, CVA, no surgical or drug history.

Personal history: 

-Diet is mixed

-appetite is normal

-sleep is adequate

-Bowel and bladder movements are regular

-no known allergies or addictions.

Family history: Father has history of similar chest pain since 2 years

General Examination:

 conscious, coherent and cooperative 

Moderately built and nourished

-No pallor 

-No icterus

-No cyanosis

-No clubbing

-No lymphadenopathy

-No pedal edema

Vitals:

PR:50 bpm

BP:130/80 mm Hg

RR:14 cpm

Temperature: afebrile

Clinical image is not available as patient did not provide consent