Here is my transcription of the case sheet from Atal Institute of Medical Super Specialities, Shimla-171 012 (H.P.) - General Case Sheet:
Name of Patient: Anil S. Sharma (or similar) CR No.: 9215126003177908
Chief Complaints with Duration:
- Chest pain for 4 hours, 14/6/26
- Smoker (C)
- DM (C) - Diabetes Mellitus
- HTN (+) - 30 years
- CAD (C)
- CVA (C)
- CLD (C)
- F/H/O Elder Brother at 40 years
History of Present Illness:
- Sudden onset, while he was sleeping
- Retrosternal, diffuse
- Moderate severity, radiating
- Non-radiating
- Not of sweating / SOB / palpitation / dizziness
Past History of Illness, Surgical Operation/Intervention, Injuries:
- Went to Kotkhai (local hospital/area) at 6 AM
- ECG + ve / -ve - Thrombolysed / Triage at 6 AM
History of any Drug or other Allergies:
- Pain subsided on 1 hour
Family History: (not legible)
Personal, Occupational and Social History:
- Again reappear
- Referred to AIIMS
- At present C/O chest pain now 8/10
- Had similar episode of chest pain on 11/6/26, subsiding at around 9:10 PM
Key Clinical Interpretation:
This appears to be a case of Acute Coronary Syndrome (ACS) / STEMI in a patient with multiple risk factors (smoker, diabetic, hypertensive for 30 years, family history of early cardiac death in elder brother at age 40). The patient was thrombolysed at a peripheral centre and referred to AIIMS/this tertiary care centre with recurrent chest pain (8/10 severity at presentation).Here is my transcription of Page 2 - the examination findings sheet:
General Physical Examination:
- Alert, oriented, comfortable (conscious/oriented/cooperative)
Per Abdominal & Per Rectal Examination:
- P/R/CVS (C) / (L/W) - (Per rectal/CVS normal or not done)
Vitals / Local Examination:
| Parameter | Value |
|---|---|
| BP | 160/90 mmHg |
| PR (Pulse Rate) | 100/min |
| SpO2 | 96-97% |
| RR (Respiratory Rate) | 18/min |
Right side:
- JVP - raised / (not raised noted)
- RS (C) - normal
- CRT (Capillary Refill Time) - normal
Examination of Cardiovascular System:
- S1, S2 - heard - NP (Normal)
- No new PSM (Pansystolic Murmur) / Tenderness
Examination of Respiratory System:
- B/L (Bilateral) - equal air entry
- NVBS (Normal Vesicular Breath Sounds) - above
- Wheeze (+)
Nervous System:
- RS - No VRES (?) / no crepitus
- No crepitus
ECG findings (circled):
- NSR (Normal Sinus Rhythm) - noted
- ST↑ (ST elevation) in V1-V6
- QS pattern in V1-V6
- QS in II, III, aVF with ST↑ - suggesting inferior + anterior STEMI (extensive)
Musculo-skeletal System:
- Power / tone - normal
Endocrinal System: (not filled)
ECG Summary:
This ECG shows ST elevation in V1-V6 (anterior leads) AND QS pattern in II, III, aVF (inferior leads), consistent with an extensive anterior + inferior STEMI, correlating with the history of chest pain and prior thrombolysis at a peripheral centre.
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