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The results were truncated. Let me now compile a full transcription from what was captured and my own visual reading of both images.

Transcription of Medical Records

Image 1 - Continuation Sheet (Annexure-B)

Patient: Onkar Singh, 64 yrs / Male Serial No / CR No: 9215/12600291595 Date: 21/6/26
Daily Progress Notes:
Referred case for PTCA / Primary PCI
  • Drugs prescribed (right column):
    • Sorbitrate (e)
    • DME (e)
    • NTG (e)
    • CPD (e) - likely Clopidogrel
    • LMWH (e) - Low Molecular Weight Heparin
    • CXDE (e)
    • ATE (e) - likely Atorvastatin
C/o chest pain at ~9:30 PM on 20/6/26 Sudden onset while he was driving Retrosternal, diffuse Mod-to-severe intensity Radiating to both arms After sweating / nausea/vomiting / SOB / palpitation / dizziness
Went to Birthing Eye Hospital (or a local hospital) Was given leading dose of Antiplatelets
AIIMS Bilaspur Was managed as NSTEMI
Today referred to AIIMS Chandigarh for PCI
  • At present: no chest pain / SOB
  • No fever / cough / -- active bleeding / 1 minute
  • SpO₂ (?), RR (?), Temp

Image 2 - Continuation Sheet + Drug Chart

Diagnosis: ACS: NSTEMI Ward: Cardiology Patient: Onkar / 66 yrs M Activity: CBR (Complete Bed Rest) CR No: 9215/12600
Drug Chart (Oral Medications):
No.Drug
1.T. Deplatt A 75 / Aspirin 75 mg
2.T. Rosuvastatin 40 mg HS
3.T. Telma 20 mg OD
4.T. Pantoprazole 40 mg BD
5.T. Clopidogrel 75 mg OD
6.T. Ranolazine 500 mg OD
7.T. Pantoprazole / Sr
8.Syrup Cremaffin / Laxative
9.(blank)
10.(blank)
Examination / Progress Notes (second continuation sheet):
O/E:
  • Conscious, Alert
  • P/P/A/CL (Pallor / Pallor / Afebrile / Clammy or similar)
Vitals:
  • BP - 100/80 mmHg
  • PR - 64/min
  • SpO₂ - 96-97%
  • RR - 18/min
CNS: 4mm NP (pupils 4mm, Non-Pursuing or Normal)
  • Upper / Lower limbs
  • S - (O) (no sensory deficit)
  • S-pain (?), pinprick
  • RVSG (O)
  • Rs - BL (bilateral) - intact
PR / Cm (Per Rectal exam / Clinical examination notes)
Investigations / Echo (ECHO findings):
  • 2D Echo:
    • RV dysfunction present
    • RA/RV mildly dilated
    • TAPSE - 15 (reduced, normal >17 mm, indicates RV dysfunction)
    • Mild TR - A 2+ (mitral/tricuspid regurgitation, 2 gradient)
    • No RWMA (No Regional Wall Motion Abnormality)
    • COIVSR (or similar - possibly coronary involvement note)
IMP (Impression):
  • IMP 1
  • R/C (Rule out / Referred for catheterization)
  • CABG? (Coronary Artery Bypass Grafting consideration)
2D Echo - UCG:
  • 2D - UCR (noted at the bottom)
  • IVC - 20 mm
  • TSO% IVC Non-Collapsible (suggestive of elevated right atrial pressure / RV failure)

Clinical Summary

This is a 66-year-old male (Onkar Singh) admitted with:
  • Diagnosis: ACS - NSTEMI (Non-ST Elevation Myocardial Infarction)
  • Presentation: Sudden onset chest pain at ~9:30 PM on 20/6/26 while driving; retrosternal, diffuse, radiating to both arms, associated with sweating, nausea/vomiting, SOB, palpitations, and dizziness
  • Initial management: Loading dose of antiplatelets given at a local hospital (possibly Birthing Eye Hospital); managed as NSTEMI at AIIMS Bilaspur
  • Referred to AIIMS Chandigarh for PCI (Percutaneous Coronary Intervention)
  • Current status at admission: No chest pain, no SOB at rest
Key findings:
  • Hemodynamically borderline - BP 100/80, PR 64/min
  • Echo shows RV dysfunction, mildly dilated RA/RV, TAPSE 15 (reduced), IVC 20 mm non-collapsible (elevated RA pressure), mild TR - all pointing to possible right heart strain or RV involvement
  • No RWMA on echo (no obvious left ventricular wall motion abnormality at this time)
  • Planned for cardiac catheterization +/- CABG/PCI
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