A 55 year old female presents to ED Department with complaints of left sided chest pain over a period of 3-4 months (Angina).

 A 55 year old female presents to ED Department with complaints of left sided chest pain over a period of 3-4 months (Angina).

The pain is worse on walking or going up hill and at times of stress and is accompanied by sweating and apprehension.

The patient also complains of swelling over both her ankles.

On examination,

Her Blood pressure is 150/90 mmHg

Her BMI is 34.

She also has Bilateral pitting oedema of feet.

Otherwise unremarkable Neurological, CV , Resp or GI examination.

1. Which initial investigations will you like to perform?

2. What are the findings on the ECG.

3. Which additional investigations would you like to perform after looking at the ECG results.

4. What is the most likely Diagnosis?

5. How will you manage this patient?

Answers given in comments section.

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1. Which initial investigations will you like to perform? 

In order to find out the underlying cause of the complaints including Angina , it would be a good idea to undertake an ECG to see if there are any findings suggestive of Ischaemic heart disease. 

Also cardiac enzymes Troponin T and Myoglobin levels are needed. A chest X ray to look for presence of Cardiomegaly suggestive of Congestive Cardiac failure as well as an Echocardiogram and BNP levels would also be useful. 

We need to look for other risk factors of IScahemic Heart disease such as raised sugar levels ( HbA1C and RBS levels ) and Serum cholesterol as well as full Renal Profile and Liver profile to determine other causes of swelling of feet.

2. What are the findings on the ECG.: 

There is t waves inversion in leads V1 - V6 which indicates ischaemia of cornary arteries supplying Anterior and lateral walls of left ventricle and interventricuar septum.

3. Which additional investigations would you like to perform after looking at the ECG results.

 Angiography , echocardiogram , Cardiac enzymes : Tropnin T and I and myoglobin , BNP , Sugar levels.

4. What is the most likely Diagnosis? 

scahemic Heart Disease / Non ST Elevation MI

5. How will you manage this patient? : 

After investigations and angigraphy, the extent and limit of coronary artery blockage is detremined and management consists of medications +/- angioplasty +/-stent insertion.

The usual cardiac medications include : Regular Ascard / loprin 75 mg once a day . Clopidrogel 75 mg once a day , GTN / sustac 2.6 mg once a day . Statins , Antihypertensives . Healthy life style : regular exercise , healthy food , Low salt and low cholesterol diet.