A 78 Y/M WITH H/O CAD

 

This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

MED CASE :- 

A 78 year old male patient came to the opd with a complaint of diminision of vision in both the eyes  since 2 years ago .

And H/O CAD 15 months back 

HOPI :- patient was apparently asymptomatic 2 years ago then developed diminision of vision in both the eyes which is Insidious in onset gradually progressive 

No history of-

• Redness of eyes
• Tufts of hair or cobwebs infront of eye 

•   Excessive lacrimation
• Diplopia
• Ocular pain or headache
•   Recent trauma to the eye or head 

PAST HISTORY:

15 months back then patient developed chest pain and epigastric pain insidious in onset gradually progressive   radiating towards left arm ; and epigastric area .

H/O palpitations present .

No H/O vomitings; headache 

No H/O PND, orthopnea present 

No H/o fever with pain, sore throat 

No H/o involuntary movement

NoH/o skin manifestations like rash, nodules

No H/o Recurrent respiratory infection
Syncope

No H/o Hemoptysis

No H/o loss of consciousness.

Then he was taken to the local hospital where ecg was done to see ECG CHANGES ;  

ST ELEVATIONS IN V2; V3 ; V4  

ECG :- 

And was referred to a cardiologist 

AND diagnosed as INFERIOR WALL MI 

AND WAS ADVICED  CAG ( Coronary artery angiography ) 

And was started on ecospirin AV ( 75/20)

And dytor ( torsemide 10 mg OD ) 

And pan 40 mg od .

ECG :- 

CAG WAS DONE ON 21/6/22 :- 

And impression was 

LMCA : Normal.

LAD : Type III Vessel, Normal.

Diagonals: Normal.

LCX : Non- Dominant, Normal.

OMS: Normal.

RCA: Dominant, Mid 95% lesion. PDA & PLVB - Normal.

Impression: CAD - Single Vessel Disease

And 

Adviced as PTCA + STENT TO RCA.

On 21 /6/2022 :- 

PTCA + STENT TO RCA (2.75 x 32 MM EVEROSHINE )  was done.

And was started on 

1. Tab. Ecosprin 75mg once daily
2. Tab. Axcer 90mg twice daily 
3. Storvas 40mg once daily
4. 4. Tab, Pan 40mg once daily before breakfast

And is on regular follow up once monthly 

For 6 months .

After that he stopped using medication due to financial issues from 6 months .

Known case of DIABETES MELLITUS II SINCE 1 month and is on medication ( Metformin 500 mg since then.

Not a known case of HTN; CVA ; Thyroid ; TB ; asthma epilepsy .

PERSONAL HISTORY:-

Diet - mixed 

Appetite- normal

Sleep - adequate 

Micturition:- decreased 

Addictions :- chronic smoker of chutta which he stopped 1 year back due to surgery . ( stent in RCA ) . 

Allergic history:- No history of any kind of allergies for food/drugs

Family history:- no significant family history 

GENERAL EXAMINATION:- 

At the time of examination :- 7/9/23

CATARACT 

MILD PALLOR 

PATIENT IS CONSCIOUS COHERENT AND CO OPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ; LYMPHADENOPATHY 

EDEMA PRESENT ( relieved in supine position) 

TEMPERATURE:- AFEBRILE

PR:

BP:110/80mmHg

RR:16cpm

CVS:

S1 S2+,NO MURMURS

RS:

BAE+ ; NVBS ; No added sounds 

P/A:

SOFT ; NON TENDER ; NO ORGANOMEGALY 

CNS :- 

NO FOCAL DEFORMITIES 

PROVISIONAL DIAGNOSIS:- 

BILATERAL SENILE MATURE CATARACT 

K/C/O CAD ( RCA STENT 15 months back) 

K/C/O DM II SINCE 1 month 

INVESTIGATIONS:- 

FBS :- 100 mg/dl

HAEMOGLOBIN     11.9 

TOTAL COUNT       5300

PLATELET COUNT     1.87  lakhs/cu mm

SMEAR:- 

Normocytic  normochromic blood picture

CUE :- 

Sugar :- nil 

Albumin:- nil

RBC :- nil

Pus cells :- 2-3 

Epi cells :- 2-3

TROP I :-  6.8 pg/dl 

RFT :- 

B.urea - 22mg/dl

S.Cr - 0.7 mg/dl

Na - 138  mEq/L

K - 4.1 mEq/L

Cl- 103mEq/L

ECG :- 

2d ECHO :- 

- Mild TR + ; Trivial AR + / MR + 

- RWMA + Anterior wall hypokinesia NO AS/MS 

-GOOD LV FUNCTION

- diastolic dysfunction + ; No PAH 

FINAL DIAGNOSIS:- 

BILATERAL SENILE MATURE CATARACT 

K/C/O CAD ( RCA STENT 15 months back) 

K/C/O DM II SINCE 1 month .