Shashank Dixit
Age: 20 years
Gender: Male
Lifestyle Factors
- • Very poor diet
- • Physically less active
- • Occasional alcohol use
- • Occasional smoking
Medical History
No diabetes, no chronic medical conditions, no significant past illnesses
Current Complaints
Primary Symptoms
Sharp left-sided chest pain
Duration: 10-15 seconds
Pain worsens with deep breathing
Exercise-induced aggravation
Frequency Progression
Last 4-5 days after moving to Bangalore
Negative Findings
- • No prolonged shortness of breath
- • No palpitations reported
- • No fainting episodes
Blood Report
Report Date
23 July 2025
Normal Parameters
CBC
Complete blood count normal
Kidney Function
All kidney markers normal
Liver Panel
Liver enzymes normal
Thyroid
Thyroid function normal
Lipid Profile
Cholesterol levels normal
Blood Sugar
Glucose levels normal
Abnormal Findings
Vitamin D
Deficient range: < 30 ng/mL
Vitamin B12
ECG
ECG Report
NormalResults
- Rhythm Normal sinus rhythm
- Heart Rate 82 bpm
- Ischemic Changes None detected
Summary: Normal ECG with sinus rhythm. No evidence of acute ischemia or arrhythmia.
ECG Tracing
Chest X-Ray Results
Clinical Findings
Clear lung fields bilaterally
No infiltrates or consolidation
Normal cardiac silhouette
No pleural effusion
Result: No abnormalities detected
Date: 23 July 2025 | Time: 14:30
1958 medical chest X-ray - historical reference
Additional Views
Doctor Notes
Clinical Assessment
Primary Diagnosis
Likely musculoskeletal chest pain (costochondritis) given sharp pain with deep breathing and recent move to Bangalore (possible stress-related tension)
Differential Diagnosis
- Precordial catch syndrome (benign)
- Anxiety-related chest pain
- Pleuritic pain (rule out infection)
Treatment Plan
- Vitamin D supplementation (60,000 IU weekly x 8 weeks)
- Vitamin B12 supplementation (oral 1500 mcg daily)
- NSAIDs for pain relief (Ibuprofen 400mg PRN)
- Stress reduction techniques
Red Flags
Seek immediate care if: chest pain >15 min, SOB, palpitations, syncope, or fever
Additional Notes
Patient education provided regarding lifestyle modification. Emphasized importance of regular exercise, balanced diet, and stress management. Advised to reduce alcohol and smoking. Reassured about benign nature of symptoms given normal investigations.
Follow-up Schedule
Next Appointments
1 Week Review
30 July 2025, 10:00 AM
Tele-consultation
4 Week Check
20 August 2025, 2:30 PM
In-person visit
Lab Review
20 September 2025, 11:00 AM
Vitamin D & B12 re-check
Action Items
- Start vitamin supplements immediately
- Track chest pain episodes
- Improve diet and start light exercise
- Reduce alcohol and smoking
Emergency Contact
24/7 Nurse Line
1800-123-4567