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Patient Profile

Shashank Dixit

20 years old, Male

Patient ID: EMR-2025-07-23-001

Lifestyle Assessment

Very poor diet
Physically less active
Occasional alcohol use
Occasional smoking

Medical History

No significant medical conditions

No diabetes, no chronic conditions, no past illnesses

Care Team

Primary Care Doctor

Dr. Rajesh Kumar

Primary Care Physician

Cardiologist

Dr. Priya Sharma

Cardiologist

Current Complaints

Active medical concerns requiring attention

Primary Symptom

Sudden sharp left-sided chest pain, sometimes near heart

Symptom Details

  • Worsens with deep breathing
  • Duration: 10–15 seconds per episode
  • No prolonged shortness of breath
  • No palpitations or fainting

Frequency Timeline

Previous

~1/week

Current

3-5/day

Increased after moving to Bangalore

Medical consultation room

Severity Scale

Pain Intensity
Frequency High

Next Steps

Immediate ECG
Chest X-ray
Complete blood work
Medical consultation

Clinical Assessment

Symptoms suggest possible musculoskeletal chest pain. However, cardiac evaluation required given severity.

Last updated: July 23, 2025 at 2:30 PM

Symptom monitoring active
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Blood Report

Comprehensive lab results from July 23, 2025

Collection Date

July 23, 2025

Normal Results

CBC Panel

Complete blood count normal

Kidney Function

All markers within range

Liver Function

AST, ALT normal

Thyroid Panel

TSH, T3, T4 normal

Lipid Profile

Cholesterol levels normal

Blood Sugar

Fasting glucose normal

Critical Findings

Vitamin D

Normal: 30-100 ng/mL

18.1

ng/mL

Vitamin B12

Normal: >300 pg/mL

<148

pg/mL

Mild Abnormality

Bilirubin

Normal: 0.3-1.0 mg/dL

1.3

mg/dL

Mild elevation - likely benign, monitor regularly

Lab report analysis

Lab Quality

Accredited lab with certified technicians

Treatment Plan

ECG Report

Normal

Findings

Rhythm Normal Sinus Rhythm
Heart Rate 82 bpm
Ischemic Changes None Detected
Axis Normal

Clinical Summary

No abnormalities detected. Normal cardiac electrical activity observed. ECG findings are consistent with a healthy young adult.

Recommendation

Continue monitoring. ECG findings do not explain current chest pain symptoms. Consider musculoskeletal evaluation.

ECG heart beat monitor ECG clock monitor ECG monitor screen
Test ID: ECG-20250723-SD Duration: 1 minute

Chest X-ray

Radiological examination - July 23, 2025

Normal

Normal Findings

Lung Fields

Clear

No abnormalities detected

Heart Size

Normal

Cardiac silhouette WNL

Detailed Observations

  • Bilateral lung fields: Clear, no infiltrates
  • Cardiac size: Normal (CTR < 0.5)
  • Diaphragm: Sharp and well-defined
  • Rib cage: Normal appearance
  • Soft tissues: No abnormalities

Imaging Details

PA

Projection

120

kVp

2.5

mAs

180

cm SID

CHEST X-RAY AP VIEW
Chest X-ray

Digital radiograph showing normal chest anatomy

Radiologist Review

Radiologist Review

Certified radiologist interpretation

Technical Quality

Penetration Adequate
Rotation Minimal
Inspiration Good

Clinical Summary

No acute findings
Suitable for comparison
Baseline established

Doctor Notes

Last updated: July 23, 2025

Primary Assessment

20-year-old male with sharp left-sided chest pain, worsening with deep breathing. No cardiopulmonary abnormalities on investigation.

Differential Diagnosis

  • • Musculoskeletal chest wall pain (likely)
  • • Costochondritis
  • • Pleuritic pain (ruled out by clear X-ray)
  • • Anxiety-related chest pain

Contributing Factors

  • • Recent relocation stress (Bangalore)
  • • Poor dietary habits
  • • Vitamin D and B12 deficiencies
  • • Suboptimal physical activity

Immediate Plan

  • • Trial of NSAIDs for musculoskeletal pain
  • • Start vitamin D and B12 supplementation
  • • Lifestyle modification counseling
  • • Reassessment in 1 week
Doctor writing notes Psychology notes Medical caligraphy

Dr. Priya Sharma, MD

Consultant Physician