Concluded Case

Cardio IM case

CASE Name: Mr. Ernesto Age/gender: 50/Male M-status: Married Date & Time: 4/29/20 & 8:00pm Chief complaint: Chest pain History of present illness: Patient is known to have hypertension since 10years. 2months PTC, patient experienced the chest pain, while climbing 1-2 steps of stair, which was relieved by rest, which sought consult, were ECG was done and result found normal, but his blood pressure was elevated. He was prescribed with Enalapril. 2days PTC, again patient experienced chest pain lasting for 45mins, which was squeezing in nature and feel like heaviness associated with difficulty of breathing and get fatigue easily. At rest, pain disappear. No medicine was taken no consult was done. 1hour PTC, patient started having severe chest pain, which was persistent and was 8/10 on scale of pain with excessive sweating, hence this prompted patient to consult at ER for further evaluation and management . Review of system: (-)Fever, (-) blurring of vision, (-) hearing problem (-) cough, (+)Shortness of breathing Past medical history: • Hypertenion for the past 10years • (-) Diabtes mellitus • (-) Asthma • (-)Tb • (-)MI • (-) Allergies • Past surgery : none Current medication: Enalapril Personal and social history: • Occupation: Retired, before use to work as seaman. • (+) Smoking: 10 cigarettes/day • (+) Alcohol drinking occasionally • (+) Caffeine beverages occasionally Family history: - Father died because of heart attack. Physical examination: - Conscious, coherent, oriented to time, place and person - BP 100/60 HR: 59/min RR: 26 cycles/min Temp 36.5 C; O2sat 98% at room air - Pink conjunctiva, anicteric sclera - No neck vein engorgement, no cervical lymphadenopathy, no neck mass or goiter - Symmetrical chest expansion, no retractions, vesicular breath sounds, no crackles - Adynamic precordium, regular rhythm, apex beat at the 6th left intercostal space anterior axillary line, no heaves, no thrills, no murmurs - Flabby abdomen, normoactive bowel sounds, soft, non-tender - No edema, no cyanosis on all extremities - Full and equal pulses - Neurologic examination: unremarkable Give the working diagnosis interprete the ECG and other labs and management in details.

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Concluded answer
Dx: ACS LVF NYHA Class IV Diabetes Stage IIIA CKD
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RISK FACTORS FOR CAD MALE . AGE 50 TOBACCO ABDOMINAL OBESITY PREVIOUS H / O EFFORT ANGINA HISTORY = SUGGESTIVE OF MI ECG = STEMI SEPTAL WALL ANTEROLATERAL ISCHAEMIA SIGNIFICANT Q IN LEAD III aVF & q. In lead I I = INF WALL INFARCTION CXR =CARDIOMEGALY LEFT ATRIAL ENLARGEMENT MANAGEMENT 1 RELIEF OF PAIN CHEST NITROGLYCERINE = SL INJ MORPHINE IM SOS 2 O2 INHALATION IF SATURATION BELOW 94 ,% OR IF DYSPNOEIC 3 CONTINUE ACE I 4 DUEL ANTIPLATELETS + PPI 24HOURS ECG MONITORING RISK STRATIFICATION 1 RECENT BP = FALL OF BP? 2 LIFETHREATING ARRHYTHMIA 3 ONGOING PAIN 4 HEART FAILURE BLOOD = ABG SUGAR CREATININE ELECTROLYTES TROP I CAG PCI WITHIN 2 HRS
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LVH with Diabetic mellitus and hypertension. Rule out vivid 19 due to age , comorbidities and shortness of breath. Needs further investigation and evaluation to conclude and treatment plan.
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BLOOD SUGAR REPORTED RAISED = INJ SHORT ACTING INSULIN TO BE ADDED IN TREATMENT
Dx: ACS LVF NYHA Class IV Diabetes Stage IIIA CKD
Anterolateral wall ischemia with LVH
Anterolateral MI and need CAG

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