Transcription of the Continuation Sheet (Annexure-B)

• Type: Continuation Sheet, Annexure-B, Page 9
• CR No.: CR No. 08G215/26002/91595
• Section: Daily Progress / Treatment
• Note top-left: "On echo / 6 days / M.A." (likely "on echocardiogram monitoring / 6 days / Medical Admission")

Assessment (Δ / Diagnosis):

• CAD = Coronary Artery Disease
• IWMI = Inferior Wall Myocardial Infarction
• RV = Right Ventricular involvement (complication)
• Killip Class: TMU - 3/14 (likely Killip Class I-II, assessed on 3rd/14th day)
• NSR = Normal Sinus Rhythm
• No edema, Rudgeful (possibly "No edema, Restful")
• Gripes / Grievous (possibly "No complaints")

Prescription (Rx):

Clinical Interpretation

• Deplatt-A (Aspirin 75 + Clopidogrel 75): Dual antiplatelet therapy - standard of care post-MI to prevent re-occlusion of the infarct-related artery.
• Rosuvastatin 40 mg (night): High-intensity statin for plaque stabilization and LDL reduction post-ACS. All ACS patients receive prompt statin therapy regardless of baseline cholesterol.
• Telmisartan 20 mg: ARB for cardiac remodeling post-MI, especially useful if ACE inhibitor is not tolerated.
• Pantoprazole 40 mg: Gastroprotection - mandatory when on dual antiplatelet therapy to reduce GI bleeding risk.
• Cremaffin syrup: Laxative to avoid straining (Valsalva) during bowel movements, which can be dangerous post-MI.
• NS infusion @ 100 ml/hr: Volume loading - this is particularly important in RV infarction, where preload is critical for maintaining cardiac output. (Nitrates and diuretics are typically avoided in RV MI for this reason.)
• Post ECG leads: Request for a 15-lead or posterior ECG to confirm RV involvement (right-sided leads V3R/V4R).

Note: Some medication names are difficult to read definitively due to handwriting - particularly items 1 and 6. The interpretation above is best-fit based on clinical context. Please verify against the original prescribing physician's order.

Patient Diagnosis

• Killip Class assessed (noted as TMU - 3/14, likely day 3 of 14-day admission plan)
• NSR = Normal Sinus Rhythm on monitor
• No edema noted; patient appears hemodynamically stable

All Treatments - Full Detail

1. Inj. Clonita / Cannula 0.6 ml SC BD

• Likely refers to Low Molecular Weight Heparin (LMWH) - Enoxaparin or a similar anticoagulant given subcutaneously
• In post-MI care, anticoagulation is given SC BD (twice daily) to prevent thrombus extension and DVT
• Alternatively could be insulin if the patient has diabetes - common in CAD patients

2. Tab. Deplatt-A 75/75 OD PC (After meals)

• Aspirin irreversibly inhibits COX-1, blocking thromboxane A2-mediated platelet aggregation
• Clopidogrel blocks the P2Y12 ADP receptor on platelets, preventing further clot formation
• Together they dramatically reduce the risk of re-infarction and stent thrombosis
• Guidelines recommend DAPT for 12 months after STEMI
• Taken after food to reduce GI irritation

"Dual antiplatelet therapy with aspirin and a P2Y12 receptor antagonist (clopidogrel, prasugrel, or ticagrelor) is recommended for 12 months after a STEMI." - Harrison's Principles of Internal Medicine, 22nd Ed.

3. Tab. Rosunn (Rosuvastatin) 40 mg OD NE (Night)

• Plaque stabilization - prevents further rupture of vulnerable plaques
• LDL cholesterol reduction (target >50% reduction)
• Anti-inflammatory effects on the coronary endothelium
• Taken at night because cholesterol synthesis peaks at night

"Lipid-lowering therapy (high-intensity statin) regardless of LDL: target LDL reduction of ≥50%; give rosuvastatin 20-40 mg PO on admission and continue daily." - Goldman-Cecil Medicine

4. Tab. Telmo (Telmisartan) 20 mg OD W (With meals)

• Prevents adverse cardiac remodeling after MI (prevents the heart from dilating and weakening)
• Controls blood pressure
• Reduces mortality in post-MI patients with reduced ejection fraction
• Standard dose in post-MI is started low (20 mg) and titrated up

5. Tab. Pan (Pantoprazole) 40 mg OD BF (Before Food)

• Aspirin + Clopidogrel significantly increases the risk of peptic ulcer and GI bleeding
• Pantoprazole suppresses gastric acid, protecting the stomach lining
• Taken on an empty stomach (before food) for maximum efficacy

6. Tab. Elpa / Alpha 0.25 mg OD NU (At Night)

• Post-MI anxiety and insomnia are common
• Reduces sympathetic overdrive which can trigger arrhythmias
• Standard admission orders for STEMI include "anxiolytic or hypnotic if needed"
• Very low dose (0.25 mg) suggests it is for mild anxiety/sleep aid only

7. Syp. Cremaffin Plus 20 ml OD NS (Night)

• Post-MI patients must avoid straining during bowel movements
• Straining triggers the Valsalva maneuver, which increases intrathoracic pressure, reduces cardiac preload, and can precipitate dangerous arrhythmias or re-infarction
• Cremaffin is a gentle osmotic + lubricant laxative widely used in Indian cardiac wards

"Stool softener" is explicitly listed in the Goldman-Cecil Medicine STEMI admission orders as standard care.

8. Inj. NS (Normal Saline) @ 100 ml/hr IV

• In RV MI, the right ventricle fails and cannot pump blood through the lungs adequately
• The right ventricle depends entirely on adequate preload (fluid) to maintain output
• IV fluid loading with NS is the primary treatment - it fills the RV and maintains cardiac output
• Nitrates, diuretics, and morphine are contraindicated in RV MI as they reduce preload and can cause catastrophic hypotension

"Management of right ventricular infarction consists of early maintenance of preload with intravenous fluids, reduction of RV afterload, early reperfusion, short-term inotropic support if needed, and avoidance of vasodilators (e.g., nitrates)." - Goldman-Cecil Medicine

+ ECG Post Leads (Circled note)

• Standard ECG only shows left-sided leads
• To confirm RV infarction, right-sided chest leads are applied
• ST elevation in V4R is the hallmark sign of RV MI
• This is why "post leads" / posterior leads are specifically requested

Summary Table

Note: This is a standard, evidence-based regimen for IWMI + RV involvement as taught in Goldman-Cecil Medicine and Harrison's Principles of Internal Medicine. The prescription follows current STEMI management guidelines. Drug names are interpreted from handwriting - always verify with the prescribing physician.