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Clinical Case Interpretation - Atal Institute of Medical Super Specialities, Shimla

Patient Details

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Image 1 - General Case Sheet

Current Medications (Drug Chart, top of page)

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Chief Complaints

• HTN (Hypertension) - ✓
• DM (Diabetes Mellitus) - ✓
• Smoking - ✓
• AWO (Awakening/possibly Breathlessness on waking) - ✓
• CAD (Coronary Artery Disease) - ✓
• CKD (Chronic Kidney Disease) - ✓
• Thyroid - possibly checked
• Duration: 3 years (noted below)
• c/o COPD (Chronic Obstructive Pulmonary Disease)

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History of Present Illness

"c/o chest pain x since 9 AM on the diffuse, radiating, awry (+), nausea (+), sepi- unwell, not blood stained, nocturia (+), a/o SOB (0), Palpitations (+)"

• Chief complaint: Chest pain since 9 AM on the day of presentation
• Character: Diffuse, radiating
• Associated symptoms: Nausea (+), not blood-stained secretions, nocturia (+)
• SOB: Absent at rest (SOB = 0)
• Palpitations: Present (+)
• Also notes: "no c/o giddiness, claudication, fever, cough, cold"

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Past History

• Urine output decreased / oliguria (likely a reference to prior CKD history)
• Prostitis (Prostatitis) +/- diuretics - history on 26/5/26, on section and Rx
• Palpitations - with "some" history noted
• No known drug allergies (blank)

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Family History

• Rxble (receivable/readable abbreviation) - Jubbal CH (likely a community health centre reference or family member from Jubbal area)

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Personal, Occupational and Social History

• Time noted: 11:30 AM (likely time of admission/consultation)
• "Load go" and "eruption" type notes (possibly occupational - laborer)
• Abbreviation of chief Rx plan noted

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Image 2 - Physical Examination & ECG Findings

General Physical Examination

"Conf, eyes open, good, admitted"

• Conscious, eyes open, cooperative/alert adult male

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Per Abdominal / Per Rectal Examination

"GC fair, JVP (+)"

• General condition: Fair
• Jugular Venous Pressure: Raised (+) - suggests right heart strain or volume overload

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Local Examination - PICCLE

• PICCLE → 0 (Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema - all absent)

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Vital Signs

Note: BP of 96/60 is hypotensive - concerning for cardiogenic shock or hemodynamic compromise in the setting of ACS.

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CVS Examination (Cardiovascular System)

• Pulse: Fair volume
• SpO2: 95% on room air
• CVS: JVP raised; S2 present, S1 normal (thrill absent)
  • S1 - present, normal
  • S2 - present, quiet
  • No S3/S4

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Respiratory System

• RS: BLAE (Bilateral Air Entry) + ; VBS (Vesicular Breath Sounds) - bilateral
• Wheeze (+) present
• Crepitations (+) - suggests pulmonary congestion, possibly early pulmonary edema

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Nervous System / ECG

"HR 94/min, LBBB" "aVF + T↓V1, V2 ; T↓V2, V3, V5, V6" "RAE (+), p 3mm lead II" "QRS S/T"

• Rate: 94 bpm
• LBBB (Left Bundle Branch Block) - new LBBB in the context of ACS is a STEMI equivalent
• T-wave inversions in aVF, V1-V2, V3, V5-V6 - widespread ischemic changes
• RAE (Right Atrial Enlargement): P wave >3 mm in lead II
• ST changes noted

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Musculo-Skeletal System

• Normal range of motion noted

Endocrine System

• NSR (Normal Sinus Rhythm? or No Specific Record)
• ST↓ III, aVF - ST depression in inferior leads (III and aVF)

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Diagnosis

CAD | ACS | NSTEMI | Fimi 4/17 (20%) | Antilip I | WAR

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Advice / Treatment Plan (Bottom right, Image 2)

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Clinical Summary

• Acute onset chest pain since 9 AM, diffuse and radiating
• Associated nausea and palpitations
• Hemodynamically borderline hypotensive (BP 96/60), tachycardic (HR 94-96)
• Raised JVP, crepitations bilaterally - signs of pulmonary and/or venous congestion
• ECG: New LBBB + T-wave inversions across multiple leads + ST depression in inferior leads (III, aVF)
• Diagnosed with NSTEMI / ACS, TIMI risk score approximately 4 (~20% risk at 14 days)

Clinical Significance of Findings

1. New LBBB in the setting of ACS is treated as a STEMI equivalent per ACC/AHA guidelines - urgent reperfusion strategy should be considered.
2. Hypotension (BP 96/60) with raised JVP and crepitations suggests possible Killip Class III-IV - high mortality risk.
3. TIMI score ~4 places him in the high-risk category requiring early invasive management (coronary angiography within 24-48 hours).
4. LMWH (enoxaparin 0.6 mL SC) is appropriate anticoagulation for NSTEMI.
5. Ticagrelor (Clavixan 75/15 represents the 75 mg aspirin + 15 mg ticagrelor or Clavixan being a brand) - dual antiplatelet therapy as per guidelines.
6. The pre-existing medications (Deplatt-A, Rosuvastatin, Metformin, Dapagliflozin, Nikorandil, Trimetazidine, Telmisartan) reflect chronic management of his CAD, DM2, and HTN prior to this acute event.

Important clinical note: The combination of NSTEMI + new LBBB + hypotension + raised JVP + bilateral crepitations in a 68-year-old diabetic smoker represents a high-acuity presentation requiring urgent cardiology review, hemodynamic monitoring, and likely early invasive strategy (coronary angiography). The low BP (96/60) warrants careful fluid management and consideration of inotropic support if cardiogenic shock develops.

• Washington Manual of Medical Therapeutics (ACS epidemiology and management)
• Tintinalli's Emergency Medicine (NSTEMI treatment and drug doses)

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Clinical Case Interpretation - Atal Institute of Medical Super Specialities, Shimla

Patient Details

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Image 1 - General Case Sheet

Chief Complaints (with vitals noted at top)

• BP: 150/80 mmHg
• PR: 88/min
• Obesity (+)
• OA (Osteoarthritis) - R/L Knee

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History of Present Illness

• Retrosternal pain
• Non-radiating
• Relieved at rest

"PIND episodes x 14 days" "2 evening DOE (Dyspnea on Exertion) - II"

• Episodes of chest pain (likely anginal/PIND = Paroxysmal Ischemic Nocturnal Dyspnea or pain episodes) for 14 days
• Dyspnoea on Exertion - Grade II (NYHA Class II) occurring in the evenings, for 14 days

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Medications noted (from top overlapping sheet)

• IV Furosemide (diuretic)
• IV Cannula inserted
• Diagnosis visible on top sheet: CHF (Congestive Heart Failure) / Mitral Stenosis / CVP - likely prior diagnosis

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Past History

"P/H" (Past History) - referenced

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History of Drug / Other Allergies

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Family History

"No H/o chest pain at rest" (family history negative)

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Personal, Occupational and Social History

"No H/o palpitations, exertional, presyncope, syncope" "No H/o PMF (Paroxysmal)"

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Image 2 - Physical Examination Page

General Physical Examination

"PR + JVP (+) (mmv rapidly)"

• Pulse present
• JVP raised (+) - elevated, rapidly rising (prominent 'v' wave or rapid upstroke)
• Suggests right heart pressure elevation / tricuspid regurgitation / fluid overload

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Per Abdominal / Per Rectal Examination

"Chest: Apex - Canda (Cardiomegaly)"

• Apex beat displaced - cardiomegaly on palpation

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Local / CVS Examination (Cardiovascular System)

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Respiratory System

"Chest: B/c (Bilateral) basal end-inspiratory fine crepitations"

• Bilateral basal fine crepitations (end-inspiratory) = pulmonary congestion / early pulmonary edema consistent with left-sided heart failure

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Nervous System

"PA / CNS - NAD" (No Abnormality Detected)

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Musculo-Skeletal System

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Endocrine System

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Background notes visible at bottom of both images (Study / Reference Sheet)

• Congenital Syphilis - fetal / early lesions: rashes, skin lesions, blisters, bullae; lesions of bones; inter-organ hepatosplenomegaly; main diagnostic criteria: SBT (Mother, Fetus)
• Gonorrhoea - Diplococcus, Peptidoglycan, non-motile, bean-shaped, Gram-negative, Penicillin resistant
• Meningitis, Encephalitis noted

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Clinical Summary & Impression

Most Likely Diagnosis:

• Pulmonary Hypertension (loud P2, S2 wide split)
• Congestive Heart Failure (raised JVP, bilateral basal crepitations, cardiomegaly, DOE Grade II)
• Hypertensive Heart Disease (BP 150/80, obesity, elderly female)

Clinical priority: Echocardiography (2D ECHO with Doppler) is the key investigation to define valve lesions, estimate pulmonary artery pressure, assess LV/RV function, and guide further management. IV diuresis (Furosemide, already initiated) for acute decompensated heart failure.

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Coronary Angiography Report - AIMSS Chamiana, Shimla H.P.

Header Details

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Laboratory / Metabolic Parameters

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Pre-Procedure ECG / Clinical Notes

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Coronary Angiography Procedure Details

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Angiography Findings

LCx (Left Circumflex Artery) - Ostium: Normal

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RCA (Right Coronary Artery) - Ostium: Normal, Reflux noted

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Summary Impression (Bottom of Sheet)

DVD (Double Vessel Disease):

• LCx → proximal ~50% (S) - moderate
• RCA → proximal ~80% (S) - severe (R) dominant (Right coronary dominant circulation)

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Clinical Interpretation

Key Findings at a Glance:

Overall Diagnosis:

• Significant RCA proximal 80% stenosis - the culprit lesion for the NSTEMI/ACS presentation
• Moderate LCx proximal 50% stenosis - may require FFR (Fractional Flow Reserve) assessment to determine if revascularization is needed

Implications:

1. RCA 80% lesion is the likely culprit responsible for the ST changes in inferior leads (III, aVF) and the troponin rise
2. PCI (Percutaneous Coronary Intervention) to the RCA proximal lesion is the standard of care - stenting indicated
3. LCx 50% - physiological assessment with FFR or iFR before deciding on intervention
4. eGFR 1.12 is critically low (likely a decimal error - possibly 11.2 mL/min = CKD Stage 4-5) - contrast nephropathy risk is very high; pre/post hydration and minimizing contrast volume are essential
5. HbA1c ~7.3% with diabetic status increases restenosis risk post-PCI - drug-eluting stent (DES) preferred
6. Elevated Troponin I (0.14) confirms ongoing myocardial injury consistent with NSTEMI

Recommendation: PCI to RCA (proximal, 80% lesion) as the culprit vessel; staged assessment of LCx; renal protection protocol given severely reduced eGFR; optimized DAPT (dual antiplatelet therapy) and high-intensity statin post-procedure.

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2D Echocardiography Report

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AORTIC VALVE

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TRICUSPID VALVE

TR velocity of 3.2 m/sec → estimated RVSP = 4 x (3.2)² + RAP = 4 x 10.24 + RAP ≈ 41 + 5 = ~46 mmHg → Moderate Pulmonary Hypertension

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PULMONARY VALVE

Pulmonary flow velocity 0.8 m/sec - low normal; Acc. Time 7.2 ms is very short, further supporting elevated pulmonary artery pressure

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2D Findings (Handwritten section below)

"4 enlarged, w @n3 to b (?) cardiomegaly" "within hypokinesia and wall motion abnormality" "akinetic wall" "hypokinesia of (anterior/inferior) wall" "aortic calcification + hypertension (+)"

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Additional Handwritten Clinical Notes (Right side)

"LSVC - 0 c dle: 0" - likely Left Superior Vena Cava assessment "1 b + 1 in 2 tan" - possibly referring to heart block or rhythm "h/o prolapsed (fail) pan (something)"

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Summary / Impression (Bottom of Sheet)

A: CAO | aorta (RCA) | severe | moderate | (?) (N) LVH / RVH (Normal LV/RV hypertrophy assessment)

राजकीय मुद्रणालय, शिमला - 23 - AIMSS चमियाना / 2024 - 12-04/2024 - 200 पैड्स

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Overall Echocardiographic Impression

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Clinical Significance

1. Ischemic Cardiomyopathy - regional wall motion abnormality (hypokinesia/akinesia) corresponding to the RCA territory (inferior wall) given the CAG finding of RCA 80% stenosis
2. Severe Aortic Stenosis - a major co-existing valvular lesion requiring AVR (Aortic Valve Replacement) or TAVI assessment
3. Moderate-Severe Tricuspid Regurgitation with Moderate Pulmonary Hypertension (RVSP ~46 mmHg)
4. Right Heart Failure features - dilated IVC, raised RAP
5. Overall this represents multi-valvular + ischemic heart disease with biventricular dysfunction - a high-risk surgical/interventional profile

Combined with the previous CAG showing Double Vessel Disease (RCA 80%, LCx 50%), this patient has complex CAD + severe AS + moderate-severe TR + pulmonary hypertension, requiring a multidisciplinary Heart Team discussion for optimal management (PCI vs CABG + valve surgery vs staged procedures).

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2D Echo Report - Page 2 (Continuation)

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Printed Form Fields (Top of Page)

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2D Handwritten Findings (Main Body)

"4 enlarged, w @n3 + (+) to cardiomegaly"

• All 4 cardiac chambers enlarged = Global cardiomegaly

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"within hypokinesia of basal inferoseptal wall"

• Hypokinesia (reduced wall motion) of the basal inferoseptal wall - RCA territory

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"akinetic basal inferior wall"

• Akinesia (absent wall motion) of the basal inferior wall - consistent with established inferior MI (RCA territory infarct)

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"hypokinesia of mid inferior wall"

• Hypokinesia extending to mid inferior wall - further RCA territory involvement

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(Calcification (+) | hypertension (+)) "it/um" - likely "in toto" or referring to diffuse involvement

• Calcific changes + hypertensive heart disease confirmed

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Additional 2D Measurements

"aortic calcific - (0) c dle: 0" "1 As + 1 in 2 tan"

• Aortic calcification - present
• Likely referencing 1 anterior + 1 inferior segment in 2 territories = 2-territory wall motion abnormality

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LV Function / RV Assessment

"1se1 doto | uydre(0)"

• Likely: LVEF estimated / RV function - moderately reduced

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Bracketed Clinical Note (Left margin)

(h/o prolapsed / fail / mitral leaflet)

• History of mitral valve prolapse / mitral leaflet abnormality (prolapse or flail leaflet noted as a prior finding or incidental observation)

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Final Diagnosis / Impression (Bottom - underlined)

Δ CAO | RVMA RLA₂ | Severe | Mod TR | PAH (N) LVH / RVH

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CBC Strip (Right Side of Image)

Anemia (PCV 30.2%) and Thrombocytopenia (Platelets 123) noted - clinically significant as both worsen myocardial ischemia and affect antiplatelet/anticoagulation decisions

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Physical Exam Note (Right side, partially visible)

"LSB - fine crepitations"

• Left Sternal Border / Lung base - fine crepitations = pulmonary congestion confirmed

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Complete Echocardiographic Summary (Both Pages Combined)

Final Echo Diagnosis:

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Clinical Case - Atal Institute of Medical Super Specialities, Shimla

Image 1 - General Case Sheet

Patient Details

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Chief Complaints (Checklist format - all circled/marked)

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History of Present Illness

"c/o giddiness (+) x 4-5 days, 4 episodes today" "each episode lasting 4-55 (seconds), with funny feeling, jerks of eyes" "not a/o fall | LOC (Loss of Consciousness)"

"no c/o Palp | SOB | chest pain | claudication"

• No palpitations, no shortness of breath, no chest pain, no claudication

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Past History

"H/o similar c/o in past (+)" - previous similar episodes

Passport (+) - (possibly "Past history noted" or referring to anticoagulation/prior procedure)

Early b/o up - possibly early blood pressure issues or prior workup

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Family History

Rxble (Receivable/Notable family history)

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Personal, Occupational and Social History (merged with Examination findings at bottom)

"Conscious, eyes open, good, admitted" "GC fair" PICCLE → 0 (all absent) JVP (+) - raised

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Image 2 - Physical Examination & Management

General Physical Examination

CVS Examination

"CVS: N1 (0) (0) thru" "S0 S2 | Thrill | PSH"

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Local Examination

"Gu 95% RA" - SpO2 95% on Room Air

RS / CM / PA → NAD (Respiratory system / Chest / Percussion and Auscultation - No Abnormality Detected)

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Cardiovascular System - Key Management Decision

"BVT ↓ evaluation" (underlined twice)

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Treatment / Advice (underlined)

Step 1 - Vagal Manoeuvres

"Vagal manoeuvres done" ↓ HR: 216/min (remained high after vagal manoeuvres - did not terminate)

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Step 2 - Modified Valsalva Done

"Modified Valsalva done" ↓ HR: 226/min (still elevated, possibly transiently increased)

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Step 3 - IV Adenosine

"Inj. Adenosine 6 mg → 12 mg → 12 mg" ↓ HR still 220/min (after first two doses)

↓ HR still 220/min (persistent)

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Nervous System Note

(+) Reflexes (noted as normal)

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Clinical Interpretation

Diagnosis: Supraventricular Tachycardia (SVT) - likely AVNRT or AVRT

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Adenosine Protocol (Standard for SVT):

If adenosine fails at 3 doses → consider IV Verapamil 5-10 mg, IV Metoprolol, or DC cardioversion (synchronized) if haemodynamically unstable.

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Differential Diagnoses for HR 220/min:

ECG is the critical next step to differentiate narrow vs broad complex tachycardia and guide definitive management. If SVT recurs after adenosine termination, electrophysiology study (EPS) + radiofrequency ablation (RFA) is the definitive cure.

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Full Case Analysis - AIMSS Shimla

Patient Details (from Image 3 - Continuation Sheet header)

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Full Transcription of All Three Pages

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Image 1 - General Case Sheet

• History of recurrent falls x 5 days, 4 episodes per day
• Each episode: giddiness, pre-syncopal
• When he slowed down, palpitation onset
• No LOC (no loss of consciousness)
• No H/o falls with injury

• HTN (+)
• No H/o SOB / chest pain (No orthopnea / dyspnea)
• Not on daily medication - implies poorly controlled or newly detected

• "No complaints vs dangerous, about treatment at local hospital" - referred from local hospital

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Image 2 - Physical Examination

• BP: 110/70 mmHg (low-normal / borderline hypotensive)
• RR: 56/min (likely PR 56/min - bradycardic)

• P - pallor; Cyanosis; JVP; Oedema; Pulsation - all negative
• Clubbing: negative

• Chest: S1 clear, S2 (N)
• No crepitations
• CVS: S1, S2 (N)
• No murmur (w murmur)

• No murmur, clear
• B/D (Bilateral) dull + non-tender on lower areas

• C2e - HMF (4) (Higher Mental Functions - 4/5 or graded 4, slightly impaired, likely due to reduced cerebral perfusion)

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Image 3 - Provisional Diagnosis, Differential, Investigations & Treatment

"Pacemaker Programming" - written as the differential/plan

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DIAGNOSIS (from Image 3 - underlined at bottom)

Δ: CAD | Old AWMI (Anterior Wall MI) | RBB (Right Bundle Branch Block) | Severe LVSD (LV Systolic Dysfunction) B/CAD - SVD (Single Vessel Disease) - LAD - diffuse - DISTCO (Distal) W/AISD (40/31/628) - likely with AISD = Anteroinferior Septal Defect or ASD with measurements Z Recurrent VT - recurrent mood shock - i.e., recurrent VT with ICD shocks / pacemaker shocks

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Summary Diagnosis

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DIAGNOSIS, DIFFERENTIAL DIAGNOSIS & TREATMENT PLAN

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PRIMARY DIAGNOSIS

Complete Heart Block (Third-Degree AV Block) complicating Old Anterior Wall MI with Severe LV Dysfunction

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DIFFERENTIAL DIAGNOSES

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TREATMENT PLAN

Investigations Advised (from Image 3)

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Treatment Advised (from Image 3 - verbatim transcription)

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Device Therapy (Primary Plan)

"Pacemaker Programming" - written as definitive management

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Comprehensive Management Strategy

Acute Phase:

1. Continuous ECG monitoring - confirm CHB vs high-degree AV block
2. IV Atropine 0.6-1.2 mg - temporary chronotropic support (limited use in infra-Hisian block)
3. Temporary pacing (transvenous) if haemodynamically unstable
4. IV Amiodarone infusion - for recurrent VT suppression (already prescribed)
5. Correct electrolytes (K+, Mg2+) - both affect conduction

Sub-acute / Definitive Phase:

1. Permanent Pacemaker implantation (Class I indication - ACC/AHA):
   • CHB regardless of symptoms
   • Symptomatic bradycardia from any AV block
2. Given severe LV dysfunction + LBBB/RBBB + recurrent VT: consider CRT-D (BiV-ICD):
   • CRT improves EF in severe LVSD with LBBB
   • ICD component prevents sudden cardiac death from VT/VF
3. Optimise heart failure therapy: ACEi/ARB (Olmesartan), Spironolactone, Beta-blocker (once stable)
4. Antiplatelet + statin for CAD secondary prevention
5. Coronary revascularisation discussion: LAD diffuse distal disease - PCI feasibility vs medical management
6. ICD programming review if existing device present - recurrent VT shocks noted

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Key Clinical Points

Adams-Stokes Attacks (paroxysmal loss of consciousness from CHB) are a Class I indication for permanent pacemaker per ACC/AHA/ESC guidelines - no further debate required; implantation should proceed urgently.

Amiodarone prescribed is appropriate for VT suppression but can further slow AV conduction - underscores urgency of pacemaker before or concurrent with amiodarone continuation.

Severe LV dysfunction (EF likely <35%) + Old AWMI + Recurrent VT = high SCD risk requiring ICD protection - ideally combined as CRT-D device.

• Braunwald's Heart Disease: "Complete AV block can result from block at the level of the AV node... acquired complete AV block occurs most often distal to the bundle of His because of trifascicular conduction disturbance."
• Rosen's Emergency Medicine: "Third-degree AV block, also known as complete heart block, is absent conduction of any atrial impulses... typically accompanied by a slow escape rhythm."

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Clinical Case - AIMSS Shimla (Mohan Singh)

Patient Details

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Image 1 - General Case Sheet

Chief Complaints

H/o TOPM + COPD | (in past) JBP (Jugular Blood Pressure / likely HBP - Hypertension)

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History of Present Illness

"c/o dizziness" "Imbalance x 2 days" "Worsening (now lying)" - symptoms worse on movement / lying

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Past History

"He was apparently well 3 days back" "Then he had sudden onset dizziness (+)" "Imbalance x 2 days" "Not a/o chest pain | SOB | palpitations" "Not a/o headache | seizures | blurring of vision"

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Family History / Personal History

• FH: Negative
• PH: Negative

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Image 2 - Physical Examination

General Physical Examination

"? le (conscious, oriented)" P | Cy | Cl, CL - Pallor / Cyanosis / Clubbing - assessed

Vitals

Local Examination

• JVP - raised
• PR (peripheral) - reduced

CVS Examination (LM section)

"CM - Apex - NP (not palpable)" - cardiac apex not palpable (cardiomegaly or poor effort)

CVS: No PSH | Thrill absent

• S1: negative (absent or soft)
• S2: normal split - present No murmurs

Respiratory System

"RS: B/L VBS (+)" - Bilateral vesicular breath sounds present "No crepitations"

• ECG ordered (circled prominently)

Musculo-Skeletal System

"PA - soft, PR (+)" - abdomen soft, pulse present

Endocrine / Neurological System - KEY FINDINGS:

"CNS: nystagmus" "Ataxia (+)" - Cerebellar ataxia present

MRI Brain ordered (right side)

"S/O Subacute infarct in post(erior) limb of (R) Internal Capsule" "(R) Frontal Gyrus (lobe)"

• Subacute infarct in posterior limb of right internal capsule
• Right frontal gyrus infarction
• Bilateral posterior circulation involvement

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Image 3 - Provisional Diagnosis, Differential & Treatment

Provisional Clinical Impression

"Thrombus" (written at top) - ischemic/thromboembolic stroke

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DIAGNOSIS

Primary Diagnosis:

CVA - Subacute Infarct in:

1. Posterior limb of (R) Internal Capsule
2. (R) Frontal Gyrus

"CVA subacute infarct in post limb of (R) Int. Capsule + (R) Frontal Gyrus 10hu"

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DIFFERENTIAL DIAGNOSES

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TREATMENT PLAN

Medications Prescribed (from Image 3):

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Comprehensive Clinical Analysis

Why This Presentation is Neurologically Important:

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Stroke Subtype Likely:

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Full Treatment Framework

Acute Phase (First 72 hours):

Sub-acute Phase (Day 3-14):

Rehabilitation:

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Investigations Still Required:

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Per Rosen's Emergency Medicine: "An emergent noncontrast CT is the standard initial imaging for potential stroke. However, it has limited sensitivity for posterior circulation strokes - MRI with DWI is superior, particularly for posterior fossa and internal capsule infarcts."

Key point: The combination of nystagmus + ataxia + dizziness in a known CAD/DM/HTN patient with MRI showing internal capsule + frontal gyrus subacute infarct represents a multi-territory ischemic stroke - the most likely mechanism is cardioembolism (from CAD/AF) or large vessel atherosclerosis of the carotid or vertebrobasilar system. Identifying the mechanism is critical because it determines whether anticoagulation (AF-related) or dual antiplatelet therapy (large artery disease) is the correct secondary prevention strategy.