Reading File
Here is a careful transcription and clinical summary of both case sheets:
Case Sheet Transcription - Atal Institute of Medical Super Specialities, Shimla
PAGE 1 - General Case Sheet
Patient: Heuna (Reena?), Age: 55F
CR No.: 90191 / 8600 289192
Chief Complaints with Duration:
- BP: 118/80 mmHg
- RR: 82/min
- Post-menopausal
- Obesity T (? /h-ton/cm)
- Family H/o (family history of something - likely hypertension/DM/CAD)
History of Present Illness:
P/H (Per History):
- Chest pain x 1 PM on 17/6/26 (onset date)
- Acute onset
- Heaviness
- Radiating to shoulders & neck
- Past history: a/h (associated with?) profuse sweating T
- No h/o palpitations, no SOS, no syncope, no syncope
- Referred to CU (Cardiac Unit) / CCU
SCU findings:
- NER (Normal Ejection Rate? / No Emergency Resuscitation?)
- STCM II, III, aVF (ST changes in II > III)
- ST depression / upgoing T in V1-V5 (STo' upgoing T V4-V5)
- Thrombolysed at ~4 PM
- Successful mitumene? (mitral?) - ECG changes + pain relief
PAGE 2 - Examination Findings
General Physical Examination:
- Went to Pvt. Hospital first
- CAG (Coronary Angiography): AOD (?)
- LAD: 70%
- LCx: 90-95%
- Right Dominance - RUSH
- Attendants not willing for PCI
Local Examination:
- Currently pain-free
Cardiovascular System Examination:
- PE = 7 CPMK (?)
- CVP: S1, (S2 circled/normal)
- S2 (circled) split
- WSME (?)
- No other added sounds
Respiratory System Examination:
- E/NR (ENR?)
- Rhonchi - Basal, bilateral, mid-posterior
- Mild MR/TR
- No PTH (no pleural rub?)
- Chest: PA / CXR - normal
Nervous System:
- EF (EF?) = 45-55% (circled)
- PVB (PVBs - Premature Ventricular Beats)
Provisional Diagnosis (right side, partially visible):
CAD - AZL - STE (Inferior + Posterior) MI
-
P/Track (with Stks = Streptokinase)
-
Successful
-
TIMI-1
-
Killip 1
-
NER
-
RWMA T (Regional Wall Motion Abnormality present)
-
Mild MR/TR
-
Borderline LVEF
-
Currently pain-free
-
No emergency complications
Clinical Summary
This is a 55-year-old post-menopausal female presenting with:
| Feature | Detail |
|---|---|
| Presentation | Acute chest pain - 1 PM on 17/6/26 |
| Character | Heaviness, radiating to neck and both shoulders, with profuse sweating |
| Diagnosis | CAD - Acute Inferior + Posterior STEMI (ST elevation in leads II, III, aVF; ST changes V1-V5) |
| Treatment | Thrombolysis (Streptokinase) at ~4 PM - successful (ECG changes resolved + pain relief) |
| TIMI flow post-lysis | TIMI 1 |
| Killip class | Class I (no heart failure signs) |
| CAG findings | LAD 70%, LCx 90-95% stenosis; Right-dominant system |
| LVEF | Borderline (approx. 45-55%) |
| Wall motion | RWMA present |
| Valvular | Mild MR and mild TR |
| Complications | None |
| PCI | Attendants declined PCI |
Key Clinical Points
-
Inferior STEMI - ST elevation in II, III, aVF is classic for RCA or dominant LCx territory occlusion. Given right dominance and severe LCx disease (90-95%), this is likely an LCx-territory inferior-posterior MI.
-
Thrombolysis was given (Streptokinase) with apparent success clinically (pain-free, ECG improvement), but TIMI-1 flow post-lysis suggests incomplete reperfusion - ideally this patient would benefit from rescue PCI, but the family declined.
-
LAD 70% and LCx 90-95% on CAG suggests significant multi-vessel disease - this patient will need medical optimization and follow-up for revascularization discussion.
-
Borderline EF and RWMA indicate myocardial dysfunction in the infarct territory.These are clearer versions of the same case sheets. Let me provide a refined, complete transcription with better legibility from these images.
Complete Transcription - Both Pages (Clearer Images)
PAGE 1 - General Case Sheet
Institution: Atal Institute of Medical Super Specialities, Shimla-171 012 (H.P.)
Patient Name: Reuna (likely Reena), Age/Sex: 55F
CR No.: 90151/8600 287/72 (or similar)
Chief Complaints with Duration:
- BP: 118/80 mmHg
- RR: 82/min
- Post-menopausal
- Obesity T / h-ton / cm (hypertension, BMI noted)
- Family H/o (family history - likely HTN/DM/CAD)
History of Present Illness (P/H):
- Chest pain x 1 PM on 17/6/26 (acute onset)
- Heaviness in character
- Radiating to both shoulders and neck
- Associated with profuse sweating T (diaphoresis)
- No h/o: palpitations, no SOS (dyspnea), no syncope, no syncope (presyncope)
- Referred to CCU (Cardiac Care Unit)
ECU (CCU) Findings:
- NSR (Normal Sinus Rhythm initially)
- ST elevation in II, III, aVF (ST > III, meaning ST elevation in II > III - suggests LCx rather than pure RCA territory)
- ST depression / upgoing T waves in V1-V5
- Arrow down →
- Thrombolysed at ~4 PM
- Successful - in terms of ECG changes + pain relief
PAGE 2 - Examination & Provisional Diagnosis
General Physical Examination:
- Went to Pvt. (Private) Hospital first
- CAG (Coronary Angiogram): BOD / AOD
- LAD: 70% stenosis
- LCx (OM): 90-95% stenosis
- Right dominance - RUSH (right-sided dominant system)
- Attendants not willing for PCI
Local Examination:
- Currently pain-free
Cardiovascular System Examination:
- PE = 7 CPMK (Pulse: 72/min likely, or PE = Precordial Examination)
- CVS: S1, S2 (normal - S2 circled as present/normal)
- S2 split (physiological or pathological splitting noted)
- WSME (? Well-sustained murmur / without significant murmur evident)
- No other added sounds (no S3, no S4)
Respiratory System Examination:
- E/NR - ENR
- Rhonchi - Basal bilateral, extending to mid-posterior zones
- Mild MR/TR (Mitral Regurgitation / Tricuspid Regurgitation)
- No PTH (no pleural rub)
- Chest PA / CXR: Normal
Nervous System:
- EF: 45-55% (Ejection Fraction - borderline)
- (2) PVBs - Premature Ventricular Beats noted
Musculo-skeletal System: Not formally noted (space used for provisional diagnosis)
Endocrine System: Not formally noted
Provisional Clinical Diagnosis (right side of page 2)
CAD - AZL - STE (Inferior + Posterior) MI
Decoded:
- CAD = Coronary Artery Disease
- AZL = possibly "Acute" (Acu)
- STE = ST Elevation
- (In + Pn) MI = (Inferior + Posterior) Myocardial Infarction
Management given:
- P/Trok (with Streptokinase - Stk)
- Successful thrombolysis
- TIMI-1 flow post-lysis (partial reperfusion)
- Killip Class 1 (no clinical heart failure)
- NER (No Emergency Resuscitation required)
Echo/Clinical Findings:
- RWMA T (Regional Wall Motion Abnormality - present, inferior wall)
- Mild MR + mild TR
- Borderline LVEF (~45-55%)
- Currently pain-free
- No emergency complications
Structured Clinical Summary
| Parameter | Finding |
|---|---|
| Patient | 55F, post-menopausal, obese |
| Risk factors | HTN, obesity, family H/o, post-menopausal |
| Presentation | Acute chest pain (heaviness) + radiation to neck/both shoulders + diaphoresis |
| Onset | 1 PM, 17/6/26 |
| ECG | ST elevation II, III, aVF (II > III); ST depression + upright T in V1-V5 |
| Territory | Inferior + Posterior STEMI (LCx dominant / RCA) |
| Reperfusion | Streptokinase at ~4 PM (3 hours after onset) |
| Reperfusion result | Successful clinically (ECG changes + pain relief); TIMI-1 angiographically |
| CAG | LAD 70%, LCx OM 90-95%, Right dominant |
| PCI | Declined by family |
| LVEF | Borderline 45-55% |
| Killip class | I |
| Complications | None |
| Current status | Pain-free |
Key ECG Interpretation Note
The pattern of ST elevation in II > III (rather than III > II) with ST changes in V1-V5 points strongly to LCx (Left Circumflex artery) territory occlusion causing an infero-posterior MI, rather than a pure RCA infarct (which typically shows III > II). This is consistent with the CAG finding of LCx OM 90-95% stenosis as the culprit lesion. The borderline LVEF and RWMA reflect the posterior/inferior wall dysfunction.
State the clinical diagnosis and state the plan pf treatment too
Finding Sources
Finding Sources
This is a different patient (Jagdev/Jogdev, Male). Here is the full transcription, clinical diagnosis, and treatment plan from both images:
PATIENT 2 - Case Sheet Transcription
Institution: Atal Institute of Medical Super Specialities, Shimla-171 012 (H.P.)
Drug and Treatment Sheet also visible (top of image 1)
Patient Name: Jagdev / Jogdev Dev, M/71 yrs (Male, ~71 years)
CR No.: 92151/26/009287/200 (approx.)
(Top of image 1 also notes: "Thrombolysed c TNK 30mg" - i.e., Tenecteplase 30mg given)
Chief Complaints (with Duration):
- Age: 71 (Male)
- Ex-smoker
- HTN (Hypertension) / on medication
- BP: 108/70 mmHg
- RR: 88/min
History of Present Illness (P/H):
- Chest pain x 7-8 AM on 18/6/25
- Acute onset
- Retrosternal heaviness
- Radiating to both arms
- Sweating (diaphoresis) T
- Went to local hospital first
- Given initial treatment (UA given? - unclear)
- Referred to AIIMS Chamiana
- Currently: EF 40-50%, pain T (pain present)
Negative History:
- No h/o: SOB, palpitations, pre-syncope, syncope
- No h/o similar complaints in past
ECG (ECU) Findings:
- NSR
- q R22 (Q waves noted)
- STE (ST elevation) V1-V5, I, aVL - (ST elevation in V1 through V5, Lead I and aVL)
- TT(T) (T wave changes)
PAGE 2 - Examination & Diagnosis
General Physical Examination:
- PE = 3 JVP (raised JVP ~ 3 cm above sternal angle)
- Wt = 58 kg
CVS Examination:
- S1, S2 - absent or distant? (written as "S1, S2 distent" - likely distant heart sounds)
- WS3 +N (S3 gallop present / S3 + N)
- No other added sounds
Respiratory System (Chest):
- Bilateral use of accessory muscles (B/L use)
- Reduced air entry bilaterally
- Mild conducted sounds
PA/CXR:
- Normal (NNL)
Nervous System:
- ALu / KI / MrTop T (likely abbreviated - Alert, oriented; minor neuro findings)
Musculo-skeletal System:
- No absolute contraindication for thrombolysis
CLINICAL DIAGNOSIS
CAD - ACS - STE (Anterior MI) (Coronary Artery Disease - Acute Coronary Syndrome - ST Elevation Anterior Myocardial Infarction)
Supporting findings:
- ST elevation in V1-V5, Lead I, aVL = classic anterior STEMI (LAD territory)
- Q waves forming in anterior leads
- TIMI - 6 (pre-thrombolysis TIMI score - very high risk)
- Killip Class 1 (no overt heart failure clinically at presentation)
- NER (No Emergency Resuscitation)
- Ongoing pain + SOB
- RWMA LAD territory / mild MR + Tricuspid Regurgitation
- Aortic LVSD (LVSD = Left Ventricular Systolic Dysfunction)
TREATMENT PLAN (as written)
As documented on the case sheet:
| Step | Treatment |
|---|---|
| 1 | Inj. LMWH 0.3 ml IV stat (Low Molecular Weight Heparin - anticoagulation) |
| 2 | Inj. Tenecteplase (TNK) 30 mg IV bolus (thrombolysis - confirmed by top note "Thrombolysed c TNK 30mg") |
| 3 | Repeat ECG after 90 minutes (to assess reperfusion) |
| 4 | Continue cardiac monitoring |
Standard Management Context for Anterior STEMI (71M, post-thrombolysis)
Beyond what is written, the standard post-thrombolysis STEMI protocol includes:
Antiplatelet Therapy:
- Aspirin 300 mg loading → 75 mg/day maintenance
- Clopidogrel 300 mg loading (if age <75) → 75 mg/day (note: at 71 years, loading dose appropriate)
Anticoagulation:
- LMWH (Enoxaparin) continued for 48 hours post-thrombolysis or until revascularization
Other medications:
- Beta-blocker (Metoprolol) - if hemodynamically stable
- High-intensity statin (Atorvastatin 80 mg)
- ACE inhibitor / ARB - especially given LVSD (EF 40-50%)
- Nitroglycerin if ongoing ischemia (cautiously)
Monitoring:
- Serial ECGs at 90 min - looking for >50% ST resolution as marker of successful reperfusion
- Cardiac enzymes (Troponin, CKMB)
- Continuous cardiac monitoring for arrhythmias
If thrombolysis fails (TIMI <2 or <50% ST resolution at 90 min):
- Rescue PCI should be considered urgently
Summary Table - Patient 2
| Parameter | Finding |
|---|---|
| Patient | 71M, ex-smoker, hypertensive |
| Presentation | Acute retrosternal heaviness + radiation to both arms + diaphoresis |
| Onset | 7-8 AM, 18/6/25 |
| ECG | STE in V1-V5, I, aVL - Anterior STEMI |
| Killip class | I |
| TIMI risk score | 6 (high risk) |
| EF | 40-50% (mildly reduced) |
| RWMA | LAD territory |
| Thrombolysis | Tenecteplase (TNK) 30 mg IV bolus given |
| Anticoagulation | LMWH 0.3 ml IV stat |
| Follow-up | Repeat ECG at 90 min + continuous cardiac monitoring |
| Diagnosis | CAD - Acute Anterior STEMI (LAD territory) |
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