I can see two pages of a handwritten medical case sheet from Atal Institute of Medical Super Specialities, Shimla (H.P.). Let me transcribe and interpret what's visible.
General Case Sheet - Transcription & Interpretation
Page 1 - History
Institution: Atal Institute of Medical Super Specialities, Shimla-171 012 (H.P.)
Form: General Case Sheet (Page 3)
Patient Name: Sandeep Kumar
CR No.: 9.21.S12.6.00.2.82639
Date: CAD (2021?) / possibly admission date
Chief Complaints with Duration:
| Complaint | Duration |
|---|---|
| HTN (Hypertension) | ~7 months (since 2021?) |
| 3mm (likely 3 months) | x kgs (weight changes?) |
| Re-Swollen (Re-swelling?) | Left + Leg |
History of Present Illness:
- C/o (complains of) chest pain and a line (possibly angina/radiating pain)
- Vitals noted: likely BP readings in a grid format:
- ~96 - 34 / ~96 - 159/89 / ~34 - 96/23 (hard to read precisely)
Past History of Illness, Surgical Operation/Intervention, Injuries:
- C/o Chest ... (possibly chest pain history)
- Untreated HT(N)? | Surgery: No | No | No
- Smoking: No (circled)
Other findings (left margin):
- 48.22 / 57245-96 (possibly weight/lab values or dates)
- SOS, K+, Na+, RFM (?), Hg (Hemoglobin?)
History of Any Drug or Other Allergies: None (nil)
Family History:
- Law (CAD?) | Cough: No | Allergy: No | Any cause...
Personal, Occupational and Social History:
- WT: 2ml / 57:45-96
- Smoking: No | Nil
Page 2 - Examination
General Physical Examination: (partially legible)
Per Abdominal & Per Rectal Examination:
- Likely: Abdominal exam findings - possibly "liver size" / "not palpable"
- Chest BLU B/L (Bilateral breath/bruit?) - possibly B/L (Bilateral) chest findings
Local Examination:
- CVS: S1, S2 (heart sounds)
- Staudia A21/2 (possibly Sternal/Apical area at 2nd intercostal space)
Examination of Cardiovascular System:
- CAO / ACS | N37EMI (possibly Normal ECG / NSTEMI?)
- Imry? / 7mm x 4 (19.1%) - possibly lesion/stenosis measurements
- NRL (Normal?)
Nervous System:
- IT 2vm
- i 4ru | Vel CAD (2mm) - possibly "vessel CAD 2mm"
Musculo-skeletal System:
- 11. Clom / Reu clony
- T. Duplista 25/25 - 1D (possibly Duloxetine 25mg? or Dupixent?)
- T. Rosun 4mg - 1m (likely Rosuvastatin 4mg - 1 month)
- T. -telime 4mg - 1D (possibly Telmisartan 4mg - 1 day)
Summary Interpretation
This appears to be a cardiology case at a tertiary care hospital in Himachal Pradesh. The patient Sandeep Kumar presents with:
- Hypertension (HTN)
- Chest pain (C/o chest pain)
- Possible ACS/NSTEMI workup (CAO/ACS, N37EMI notation)
- Possible CAD (Coronary Artery Disease) - "Vel CAD 2mm"
- Prescribed medications appear to include Rosuvastatin (statin) and Telmisartan (ARB for hypertension)
Note: The handwriting is quite difficult to read in several places, and some interpretations above are best-effort estimates. Critical clinical decisions should always be verified against the original document with the treating physician.
Identify this ecg
This is the ECG of the same patient - Sandeep Kumar Shar, 65Y Male, ID 2859.
ECG Analysis
Machine-Reported Parameters
| Parameter | Value |
|---|---|
| HR | 60 bpm |
| P-R interval | 166 ms |
| QRS duration | 100 ms |
| Axis | 66° (Normal) |
| P/T (ms) | 112 / 147 |
| QT/QTc | 412 / 412 ms |
| RV1/RV5 (mV) | 0.51 / 0.27 |
| RV5/SV1 (mV) | 1.05 / 0.72 |
Machine Interpretation
- 800 - Sinus Rhythm
- 742 - Lateral Abnormal Q (<18 ms) - likely septal Q waves in lateral leads
- 601 - T Abnormality
- *** Undefined Abnormal ECG ***
Visual ECG Interpretation
Rhythm
- Sinus rhythm, HR ~60 bpm, regular
Key Findings
1. Lateral Abnormal Q waves (Leads I, aVL, V5-V6)
The machine flags lateral Q waves. In this clinical context (65M, HTN, chest pain, possible CAD), these likely represent:
- Old lateral MI (past myocardial infarction), or
- Septal Q waves (physiological, from normal septal depolarization)
- The distinction matters clinically - pathological Q waves are >40ms wide and >25% of R wave depth
2. T Wave Abnormality (Code 601)
- Likely T wave flattening or inversion in lateral leads (I, aVL, V5-V6)
- In the context of chest pain + ACS workup: suggests myocardial ischemia / lateral wall involvement
3. Precordial leads (V1-V3)
- V1-V3 show relatively small R wave progression - possible poor R wave progression, which can indicate anterior ischemia or old anterior MI
4. QTc = 412 ms - Normal (borderline upper limit, not prolonged)
5. Axis = 66° - Normal axis
Clinical Correlation
Given this patient's profile (65M, hypertension, chest pain, case sheet noting ACS/CAD, prescribed Rosuvastatin + Telmisartan):
| Finding | Significance |
|---|---|
| Lateral Q waves | Possible old lateral MI or prior CAD event |
| T wave abnormality | Lateral ischemia - could indicate NSTEMI or unstable angina |
| HR 60, Sinus rhythm | Hemodynamically stable |
| Normal QRS duration (100ms) | No bundle branch block |
Most Likely ECG Diagnosis:
Sinus rhythm with lateral ischemic changes - consistent with CAD / possible old lateral MI with ongoing lateral ischemia (NSTEMI pattern). This correlates strongly with the case sheet notation of CAO/ACS and CAD.
⚠️ Clinical Note: The machine explicitly states "Report needs clinician review." This ECG should be interpreted in full clinical context by the treating cardiologist, with serial ECGs and troponin levels to differentiate old MI from acute ischemia.
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