Reading File
Here is a full transcription and clinical interpretation of both handwritten case sheets:
Page 1 - General Case Sheet
Institution: Atal Institute of Medical Super Specialities, Shimla-171 012 (H.P.)
Patient Name: Saheb Singh
CR No.: 9AILS/126.00.274267
Chief Complaints with Duration:
- C/o Chest pain since 5 am today
- Sudden onset while he was sleeping
- Retrosternal, diffuse
- Mod. intensity, radiating to both shoulders
- Associated with sweating, nausea/vomiting, eots (belching?), palpitations
History of Present Illness:
- Went to Sunni Civil Hospital
Past History of Illness / Surgical Operation / Intervention / Injuries:
- KBSS-473 (likely a hospital reference/case number from previous visit)
- SCS c/o TWMI (Thrombolysis for TWMI - likely TEMI / STEMI - ST Elevation MI)
- Loading dose of Antiplatelets given
- Referred to AIIMS (All India Institute of Medical Sciences)
History of Drug or Other Allergies:
- Referred to AIIMS (repeated note, possibly "went to AIIMS")
Personal, Occupational and Social History:
- Thrombolysed @ AIIMS at 12 pm
- Referred to AIIMS
- At present - oral bleeding noted
Page 2 - Examination Sheet
Name: Saheb Singh
Ward: Room (Cardiology ward implied)
General Physical Examination:
- No fever (afebrile)
- (Some features partially illegible - "n y/o female/male")
Per Abdominal / Per Rectal Examination:
- Soft / nontender (partially legible)
Local Examination:
- C/o Chest - Conscious, oriented
- PTRCy 10/cm (possibly PR/Pupils - pupils reactive to light)
Examination of Cardiovascular System:
- BP: 110/70
- HR: 86/min
- JVP: raised (R)
- SpO2: 96%
- RR: 18/min
- CVS: Apex shifted, no thrills/heave
- S1 S2 heard, no murmur
Examination of Respiratory System:
- B/L air entry present
- No rhonchi/crepts
- S1+S2 with no added sounds
ECG Findings (noted in right margin):
- ST elevation in leads II, III, aVF (inferior leads) - consistent with Inferior STEMI
- ST elevation in V1-V4 as well (anterior extension?)
- ST depression in aVL
Nervous System:
- No Pallor/Pallor (not sure)
- B/L - normal
- No crepitus
Musculoskeletal System:
- Legs - normal
- WNL (within normal limits)
Endocrinal System:
- Re-reviewed
- No lymphadenopathy
- PR - normal / WNL
Clinical Summary
This is a case of an acute STEMI (ST-Elevation Myocardial Infarction), most likely inferior wall MI (ST elevation in II, III, aVF), with possible anterior extension (ST changes in V1-V4).
Key clinical points:
| Feature | Detail |
|---|---|
| Onset | Sudden, during sleep, ~5 am |
| Pain | Retrosternal, diffuse, moderate intensity, bilateral shoulder radiation |
| Associated | Sweating, nausea/vomiting, palpitations |
| Initial management | Went to Sunni Civil Hospital → KBSS → antiplatelet loading dose |
| Thrombolysis | Thrombolysed at AIIMS at 12 pm (Tenecteplase/Streptokinase likely) |
| Complication | Oral bleeding post-thrombolysis (hemorrhagic complication) |
| Vitals on arrival | BP 110/70, HR 86, SpO2 96%, RR 18 - hemodynamically borderline |
| ECG | ST elevation II, III, aVF + V1-V4; ST depression aVL |
The oral bleeding noted at present is a recognized complication of thrombolytic therapy (fibrinolytics). This needs urgent assessment - check gums, oral mucosa, and ensure no other bleeding sites. Platelet function is also impaired from antiplatelet loading.
Next steps typically indicated:
- Urgent coronary angiography (post-thrombolysis rescue PCI if needed)
- Monitor for bleeding complications (CBC, coagulation profile)
- Oral/dental examination for source of bleeding
- Hold further antithrombotic therapy if active bleeding significant
- Echocardiography to assess wall motion abnormality and LV function
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