65yr / F, presented with c/o SOB since morning, can not lie down. She was having SOB on exertions and nocturnal dyspnoea since 4-5 days. She is hypertensive and hypothyroid on Telsertan 40, Metprolol 50, Amlodepin5 and Thyroxin 75 as advised by her consultant. CBC, Biochemical profile, TSH, ECG, Echocardiogram, CXR enclosed.

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There is Inferior wall ischemia as denoted by ST depression in II, III and aVF leads. Plus she has Pulmonary Artery Hypertension which may be secondary to Pulmonary Embolism I suggest the following: 1. Coronary Angiography 2. D-Dimer test and Serum FDP to R/O Pulmonary Embolism. If positive, there is high likelihood of Pulmonary Embolism. In that case, Diagnostic modality of choice is CT Pulmonary Angiography. Don't ignore Hyponatremia as well and find out underlying cause of it. But first address her acute SOB. There should be no harm in giving 325 mg Aspirin and Clopidogrel 150 mg.

Thanks. Points noted Sir.
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Pulmonary embolism. Ldh.d.dimer.pulmonaryangiography

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Ac.Pul.oedema

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St depressions in lateral leads indicating inferior wall ischemia...To do troponins ntprobnp and d-dimer...To send across serum omalality and iron spot sodium.. Probably hypervolumic hyponatremia...Chest x-ray shows bilateral minimum pleural effusion indicating fluid overload...Probably right heart failure secondary to severe PAH...To be started on diuretics, anti platelets heparin and NIV if required...Would require ICU hospitalization

Thanks. She is in High Dependency unit under intensive monitoring and being managed with diuretic Antiplatelets statins ..... and stable with room air now.
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Inferior wall ischemia

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BNP tropi FDP fluid resertriction. Acs therapy Niv with high peep angio

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ECG : T inversion in lead II, III, aVF with reciprocal changes in V5, V6. ((Inferior Wall Ischaemia)) ; Sinus Tachycardia

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LVH with strain

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Sir ECG SHOWS inferior wall ischemia.

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