60years old male with c/o chest pain and SOB since 30 min

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



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on 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 come up with diagnosis and treatment plan.

Chief complaints 
Patient came to casuality wity complaints of 
Chest pain since 30 mins 
Palpatations since 30 mins 
Sweating 30mins 

HOPI - 
Patient was apparently asymptomatic 30 min back then he developed chest pain insidious in onset gradually progressive  radiating to left shoulder and scapula region no aggrevating and relieving factors 
With occasional palpatations and profuse sweating since 30 min.



Past history -
N/k/c/o HTN,DM,Asthma, Epilepsy,thyriod disorders CVA,CAD

 Personal history -
Diet - Mixed 

Sleep - Adequate 

Appetite - normal 

B&B - regular 

addictions -no 
 
Family history- 

No significant family history
 
General examination -

Patient was conscious coherent co-operative
 
Pallor - present
No icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS

Temperature - 98.2

BP- 180/100mmhg

PR -120 bpm

RR-32 cpm

Spo2 84% 12 lit  O2 room air 

Grbs- 120

Clinical images 
Investigations
Ecg 
Ech after thrombolysis
Troponin - I
193 pg/ml 
Serum potassium- 3.8
Serum creatinine - 1.1
 Systemic examination
Cvs - S1 S2 present 
R/s - bilateral air entry present b/l crepts present IMA,ISA,IAA 
Wheeze present 
CNS - NFND 

Provisional diagnosis :
Extensive evolving anteroseptal wall Myocardial infarction with cardiogenic pulmonary edema 

 Treatment history - 
1)Inj lasix 40mg iv/stat 
2)inj.ondesarton 4mg iv/stat
3)inj.dobutamine 2.5ml/hr iv/stat increase are decreasing according to MAP 65mmhg
4)Noradrenaline 4ml/hr iv/stat 
5)Tab.ecosprin 325mg po/stat
6)Tab.clopidogrel 300 po/stat
7) Tab.atorvas 80mg po/stat 
8) inj.NTG 1ml in 4ml ns 1cc iv stat
9)inj.tramadol 1amp in 100 ml NS slow iv
10)NIV 















 


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