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

Page 1 - General Case Sheet

Chief Complaints with Duration:

• H/o Syncope - 3 episodes yesterday

• DM x 20 years (Diabetes Mellitus, 20-year history)
• HTN x 20 years (Hypertension, 20-year history)
• Dyslipidemia (circled - active)
• HypOThy (Hypothyroidism)
• Obesity (circled - present)
• OSH (Outside Hospital) - circled
• COPD (circled - active)

History of Present Illness:

• Patient was apparently well till morning of 12/6/25
• She had episodes of LOC (Loss of Consciousness) lasting a few seconds
• Associated with self fall and regaining of feet (i.e., fell and then recovered consciousness spontaneously)
• Conscious after episodes (implies brief, self-limiting events)

Past History (Illness, Surgical, Injuries):

• Not preceded by palpitations
• Not followed by seizure / urination / biting of tongue / retention
• Not associated with position change / tingling / vertigo

Drug/Allergy History:

• No allergies; Chest pain mentioned (possibly as a symptom, not allergy)

Family History:

• Yes - SOR / NYHA (possibly heart disease or dyspnea-related family history)
• F/H of IP (possibly Ischemic Paranoia or Ischemic Pathology - likely ischemic heart disease)

Personal, Occupational, Social History:

• More symptoms in winter season / early morning
• H/o fever (101°F) with redness
• No cough / burning micturition

Page 2 - Physical Examination

General Physical Examination:

• 96 - Compos mentalis (GCS fully alert, oriented)
• P/4/Cyl (C/cir) - likely Pulse: 4-beat, cyclical character (possible to interpret as regular)

Per Abdominal & Per Rectal:

• BP: 160/60 mmHg (wide pulse pressure - suggestive of aortic regurgitation, atherosclerosis, or isolated systolic hypertension)
• PR: 78/min (pulse rate 78)
• JVP: 0 (not raised - no evidence of right heart failure)
• R/e: 0 (Redness: absent?)
• Ca-Pan: 0 (calcium panniculitis absent)

Local Examination:

• GCS: 4E7 VO2 (likely GCS E4V5M6 = 15, fully conscious - hard to read precisely)
• PR2: 125/20/min (possibly respiratory rate or secondary BP reading)
• RBS: 448 mg/dL (Random Blood Sugar = 448 mg/dL - severely elevated, consistent with poorly controlled DM)

This RBS of 448 mg/dL is critically high. In a patient with 20-year DM history, this warrants urgent glycemic management.

Cardiovascular System (CVS):

• CVS: Apex NP (apex not palpable / normal position)
• S1 S2 / murmur: 0 (heart sounds present, no murmur)
• ECG: NCR (Normal Cardiac Rhythm? / No Conduction abnormality)
  • HR: 76/min
  • PR: 120ms (normal)
  • QRS: 80ms (normal)
  • QTc: 440ms (upper normal range - borderline long, worth monitoring in a diabetic on multiple drugs)

Respiratory System:

• By - Soft (bilateral soft breath sounds)
• B/L bi-basal crackles (bilateral basal crepitations - suggests possible early pulmonary congestion or lower lobe COPD/infection)
• Az: 1Hz (possibly reduced air entry)
• No S/m (no stridor/murmur)

Nervous System:

• ECHO: All volumes and chambers (N) (Echocardiography - all chambers normal volume)
• RO reflexes: B/L 4/5 (reflexes present bilaterally)
• Trivial MR/TR (Trivial Mitral Regurgitation and Tricuspid Regurgitation - clinically minor)
• WTN / RVS R (Wall thickness normal / RV systolic right)
• MAC+ (Mitral Annular Calcification - present, consistent with age, DM, and hypertension)

Musculo-Skeletal System:

• Wt-elbow (weight bearing on elbow? or waist elevation)
• Knee jt 1/5 (reduced knee joint range or power)

Endocrine System:

• Erma - Euthyroid (likely on thyroid replacement and currently euthyroid)

Clinical Summary & Interpretation

1. Cardiac syncope - Must be ruled out given her DM, HTN, COPD, and wide pulse pressure. Suspected cardiac syncope warrants admission and further monitoring per textbook guidelines (Symptom to Diagnosis, 4th Ed).
2. Metabolic syncope - RBS 448 mg/dL in a long-standing diabetic could cause cerebral dysfunction/autonomic neuropathy leading to syncopal-like events.
3. Vasovagal / Reflex syncope - Brief, self-limiting episodes with spontaneous recovery; however, absence of typical triggers (emotion, prolonged standing) makes this less likely.
4. Hypoglycemia-induced LOC - Should not be excluded even with high RBS at time of check (Somogyi effect).
5. COPD-related hypoxic episode - Bilateral crackles present; in the setting of respiratory compromise, transient hypoxia can cause LOC.

• Serial ECGs and 24-hour Holter monitoring
• Echocardiography (already done - normal chambers/volumes)
• HbA1c, fasting glucose, insulin profile
• ABG (given COPD and bilateral crackles)
• TFTs (on hypothyroid treatment)
• CBC + CRP (fever 101°F - rule out infection)
• Orthostatic vitals
• Tilt-table test if no cardiac cause found

Important note: This interpretation is for educational and informational purposes. Clinical decisions must be made by the treating physician based on the full clinical picture. The RBS of 448 mg/dL is a significant acute finding that requires immediate attention by the care team.

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

Page 1 - General Case Sheet

Chief Complaints with Duration:

• 60/26 (likely date: 6/6/26 - first visit or complaint onset)
• 15/6/26 (current date of presentation or follow-up)

History of Present Illness:

• IHA / RDA - likely shorthand for IHD (Ischemic Heart Disease) queries or more probably in a 24-year-old: RDA = Right-sided Disease / Right heart Acyanotic or this refers to a prior diagnosis abbreviation
• NSp (1) - Non-specific finding #1
• RAPVC (1) - likely Right Atrial Pressure / Volume Change, or possibly RAFVC = Right Atrial / Ventricular finding - flagged as item 1

Past History:

• No PAH - No Pulmonary Arterial Hypertension (confirmed absent or ruled out)

Advice (Prescriptions written in this section - unusual placement, likely an OPD prescription):

1. Inj. Augmentin 1.2g IV BD - Injection Augmentin (Amoxicillin-Clavulanate) 1.2g intravenous, twice daily - broad-spectrum antibiotic for respiratory/systemic infection
2. T. PCM 650mg 1 tab - Tablet Paracetamol 650mg, 1 tablet (for fever/pain)
3. T. Pan 40y 1od BGF - Tablet Pantoprazole 40mg once daily before food (gastric protection, especially with antibiotics)
4. T. Afrax 0.25g 1 tab - Tablet Afrax (likely Azithromycin 250mg), 1 tablet - macrolide antibiotic, possibly for atypical respiratory infection coverage

Page 2 - Physical Examination

General Physical Examination:

• Norm of com-tongue (?) (normal tongue? or some milestone)
• LSCS - Delivery (born via Caesarean section)
• Uncircumfised (not circumcised - male child? or notation about the prior patient)
• Cried at birth (positive birth cry - good perinatal status)
• No seizures
• Achieved all milestones as peers

This developmental notation strongly suggests this may actually be a pediatric patient being evaluated for congenital heart disease, with the age "24y" possibly being a misread - it could be 24 months (2 years old), which would make far more sense given the developmental milestones being documented.

• Incidental Dx of suspected (incidental diagnosis - something found on workup)
• Admitted for evaluation
• AeD (Aortic/edema finding, possibly "Admitted for evaluation" notation)

Local Examination:

• No H/o SOB / Palpitation / Croup / Hoarsegurgle / Chest pain
• No H/o Cyanosis / Cyanotic spells / Squatting

The absence of squatting and cyanotic spells argues against Tetralogy of Fallot or other cyanotic CHD.

CVS Examination:

• Cons, Oriented (Conscious and oriented)
• P1P1Cy/C1/Cw (Pulse character - likely regular, good volume)
• BP: 110/60 mmHg - normal
• PR: 120/min - tachycardia (in a child, HR 120 can be normal)
• SpO2: 96% - mildly reduced (normal >98%)
• PR: 18/min (respiratory rate - normal for a child)
• JVP: 0 (not raised)
• Pedal edema: 0
• CaRom C (likely Cardiomegaly - absent, or "Cardiac Sounds - Clear")

Cardiovascular System:

• CVS: Apex 3rd ICS no @cms - apex beat location noted
• Norm obtained (normal findings)
• No Pan / Thrill / Palpable S2 - no pansystolic murmur, no thrill, no palpable second heart sound

Endocrine System:

• Pulse <(1) - Rest Rep. (resting, regular)
• (n) - Ree. (Normal - Regular)

Prescription Analysis

The combination of IV Augmentin + oral Azithromycin is a standard CAP (Community-Acquired Pneumonia) dual-coverage regimen, targeting both typical and atypical pathogens. This aligns with SpO2 of 96% and likely respiratory symptoms.

Clinical Summary

• Probable respiratory infection (CAP or lower respiratory tract infection) - treated with Augmentin IV + Azithromycin
• An incidental finding on examination possibly suggesting an acyanotic congenital heart disease (no cyanosis, no squatting, no cyanotic spells, SpO2 borderline 96%, admitted for evaluation)
• The developmental milestone documentation (born by LSCS, cried at birth, milestones normal) points toward a pediatric workup
• No PAH documented in past history - favors early or mild CHD if present
• Normal BP, no raised JVP, no pedal edema - compensated cardiac status

1. Community-Acquired Pneumonia (CAP) - primary acute illness driving admission
2. Incidental acyanotic CHD (ASD/VSD/PDA suspected) - detected during evaluation, to be confirmed by echocardiography

Note: The handwriting on these sheets is dense and partially overlapping. Some abbreviations have been interpreted based on clinical context. The treating physician's notes are the definitive reference. If this is a pediatric patient, drug doses for Augmentin should be weight-based (standard pediatric IV dose: 30mg/kg/dose of amoxicillin component), and the 1.2g adult dose listed suggests this may indeed be a young adult rather than a toddler.