Professional Documents
Culture Documents
Presented by
Dr. Mohammed Mushfiqur Rahman
Dr.Rushdi Gazal
01/06/2015 – 12:10
66 yrs male transferred as life
saving case to KSMC from
Aleman Hospital by
ambulance.
01/06/2015-12:10
ER doctor note:
chief complain; chest pain started yesterday night
k/c of DM on insulin , IHD, S/P Cath 5 yrs ago . Pain
started yesterday went to Aleman Hospital two hrs
ago where he received thrombolytic therapy
BP: 117/67 , HR :90/min, RR:20, sO2 : 90% ,
temp:36.8 , glucocheck:110mg/dl , pain score 3/10
Alert , conscious , oriented, no neurological deficit
Chest clear equal air entry
Abdomen soft lax
CVS: S1+S2+0, no Lower limb edema
Initial impression : ACS
Requested labs and chest X-ray
01/06/2015- 17:25
Pt referred to cardio
66yrs old male pt k/c of DM,IHD
Come with referral from Aleman Hospital after
receiving thrombolytic therapy
ECG: LBBB, +ve tropoine
For your kind care.
01/06/2015- 19:30
Cardiologist note: this 66 yrs old male non-
smoker K/C of DM, dyslipidaemia , IHD S/P Cath
5yrs back with stent.
Presented with chest pain for 9-10 hrs duration
came from other Hospital S/P streptokinase, pain
was radiating to neck and associated with
sweating and SOB.
BP:104/36 , HR : 97/min, So2: 97% with O2
Head neck normal
Chest clear
CVS S1+S2+0
Abdomen soft lax
CNS intact
Impression: Acute MI S/P streptokinase from another
hospital
LBBB , DM, HTN, IHD.
Consultant impression:
Transient LBBB, anterior wall MI, old IHD post PCI DM,
dyslipidaemia.
Treatment given:
Inj Clexan 60 mg subcut BID
Tab Aspirin 81 mg po once daily
Tab Plavix 75 mg po once daily
Tab Atrovastatin 40 mg PO once daily
Tab Concor 2.5 mg po once daily
Tab Capoten 6.25 mg po once daily
Tab Isordil 5 mg subligual PRN
Tab Zantac 150 mg po bid
Inj Regular Insulin subcut in sliding scale with
glucocheck 6 hrly
Pt transferred to CCU 01/06/2015- 21:00
Pt seen by CCU doctor at 21:30- 01/06/2015.
66yrs old male non smoker k/c of Dm , Dyslipidaemia, IHD post Cath twice
2yrs and 5yrs back.
Presented to another Hospital with history of chest pain for 9 hrs treated as
Acute MI post SK.
On Ex : conscious oriented, No chest pain or SOB.
HR :80/min, BP: 104/47mm Hg
Chest: clear
CVS: S1+S+2+0
Abdomen: soft and lax
ECG: SR, LBBB transient
Lab: CK 1452, CK-MB 129, trponin : 6.75
Plan:
Detailed Echo
Trace fax result
D/c concor
Start metaprolol 25mg BID
02/06/2015-11:30
Consultant note:
Old IHD, post PCI
Transient LBBB
Acute MI post SK
EF 35%
Stable no complain
BP 107/80, HR 90/min, sO2 100
Chest: clear
CVS: S1+S2+0
Plan:
Fax to PSCC
Medical referral for DM and peripheral neuropathy
02/06/2015 11:30
Echo study by consultant:
Sever MR
3 vessels disease
05/06/2015-11:30
pt is dysphonic, on ionotrope, BP: 92/45, HR: 130/ MIN
Chest: bilat crackles.