the following lawyer 48yrs with the Ecg came to old with chest pain of one day history. it is associated with difficulty in breathing and diaphoresis. the pain refers to left shoulder. his blood works are all normal except for triglyceride which is raised and chest X-ray was normal. he has positive history of heart disease. his bp is 120/80. he had similar episodes more than 10 times earlier everytime when he is in stress. he was examined and investigated 2 months back but no cause has been found. systemic examination has no abnormality. otherwise patient doesn't have any other complain. how to proceed in this case.

When our patients talk about Dizziness , What do they mean ? Please note :This is not an exhaustive text on the topic, but only meant to create awareness Most of us might have had a feeling of unsteadiness or a spinning sensation in their heads at some point or other in Our lives. It is also called as Giddiness by a few of them. I always feel giddy and nauseous whenever I am in the amusement parks and if I were to climb those great wheels or those turnarounds , I am definitely going to become sick and debilitated for the rest of the evening. For that matter, I am also a victim of motion sickness, even spinarounds and being driven on up and down hills can make me giddy and sick. You might laugh if I say that I feel dizzy even when I am standing at edge of high heights like from a building or a cliff. Dizziness or Giddiness is a broad term that can mean different things to different people. It's a common complaint, but it can be serious. Dizziness has no specific medical meaning, but there are four common conditions that can be considered types of dizziness: VERTIGO :  The feeling of motion when there is no motion, such as one feels spinning or the environment spinning. Spinning yourself round and round, then suddenly stopping, can produce temporary vertigo. But when it happens in the normal course of living, it signals a problem with the vestibular system of the inner ear -- the body's balance system that tells you which way is down and senses the position of your head. About half of all dizziness complaints are vertigo. LIGHTHEADEDNESS : Also called near syncope, lightheadedness is the feeling that you are about to faint. It is commonly felt by standing up too quickly or by breathing deeply enough times to produce the sensation( hyperventilation). I,myself had this problem during my school days, standing in the school assembly for long periods. DISEQUILIBRIUM : A problem with walking. People with disequilibrium feel unsteady on their feet or feel like they are going to fall. ANXIETY: People who are scared, worried, depressed, or afraid of open spaces may use "dizzy" to mean frightened, depressed, or anxious. Frequent dizziness sufferers may complain of more than one type of dizziness. For instance, having vertigo may also make them anxious. Dizziness can be a one-time event, or it can be a chronic, long-lasting problem. Nearly everyone who is dizzy will get better over a period. This is because a person's sense of balance is a complex interaction between the brain, each ear's separate vestibular system, sensors in the muscles, and sense of vision. When one component breaks down, the others usually learn to compensate. What Causes Dizziness? Vertigo can be caused by many things: INFECTIONS, such as the ones that cause the common cold  can cause temporary vertigo via an ear infection. This inner ear infection is generally viral, harmless, and usually goes away in one to six weeks, but drugs are available if it is severe. Benign Paroxysmal Positional Vertigo -- Positional Vertigo( BPPV ) is caused by movement of an otolith -- a tiny calcium particle the size of a grain of sand -- from the part of the ear that senses gravity to the part that senses head position. The person feels as if their head is turning when it isn't. A two-minute therapy, Epley maneuver done in the proper way can move the otolith back where it belongs and fix the problem. This therapy cures vertigo 80% of the time. MENIERE's disease is a disorder characterized by long-lasting episodes of severe vertigo. Other symptoms of Meniere's disease are tinnitus (ringing in the ear), hearing loss, and pressure or fullness in the ear. DANDY's syndrome is a feeling of everything bouncing up and down. It can happen to people who take an antibiotic that is toxic to the ear. It usually improves over time.Less common, deadly diseases can also cause vertigo, such as tumors or stroke. Lightheadedness is usually caused by some surrounding circumstances impairing blood flow to the brain when a person is standing up. Blame this problem on our ancestors who learned to walk upright -- putting our brain above our heart. It's a challenge for the heart to keep the brain supplied with blood( auto regulation mechanism) and it's easy for this system to break down. When blood vessels in the brain become dilated, or expand, due to high temperature, excitement, or hyperventilation, alcohol consumption, or prescription medications such asantidepressants, a person can become lightheaded. There can also be more serious causes, such as astroke and heart disease. DISEQUILIBRIUM can be caused by: A kind of arthritis in the neck called Cervical spondylosis, which puts pressure on the spinal cord. Parkinson's disease or related disorders that cause a person to stoop forward. Disorders involving a part of the brain called the cerebellum. The cerebellum is the part of the brain responsible for balance and coordination. Diseases such as diabetes that can lead to loss of sensation in the legs,as in advanced cases of neuropathy. Dizziness in the form of anxiety is often, but not always, caused by depression. It can also be due to an anxiety disorder or phobia or a panic disorder. Various medications can also cause dizziness as a side effect. ref:webmd.

A 37 yo female with a history of anxiety disorder presents with concern for panic attack. She describes a sensation of palpitations, racing heart rate, severe dyspnea, and lightheadedness. She is beginning to feel some chest heaviness. has a several-year history of these intermittent symptoms, like panic attacks. often last for 10-15 minutes and spontaneously subside. What does ecg says.

33 y/o female with chest pain, difficulty on breathing, and heart palpitation. diagnosis???

Incidental finding in a 60 y/o female c/o 10 month hx of unrelieved diarrhea w/ associated 65 lb weight loss. Hx anxiety, ulcers, Bell's palsy. Takes associated meds. No allergies. HR 70, BP 103/67, RR 18, SpO2 96% RA. Pt. transported w/o incident. IV established, received 250 ml fluid. Denied hx of liver disease, cancer, c. diff, foreign travel, or other GI issues besides past ulcers.