cardiology case report...an example

CARDIOLOGY CASE REPORT

Presented by: Vaibhav V. Kalgaonkar

Made by: Dipayan Banerjee

Passport Data

Name: Premarchuk Yevdo IvanivnaAge: 64 yearsSex: FemaleAddress: Village BuadkivskiOccupation: PensionerDate of admission: 12/01/2015Diagnosis: Angina pectoris, unstable, destabilization from 11/01/2015

Complains

• Chest pain behind sternum, irradiating to left arm, intensive

• Pain starts after emotional stress or physical activity

• Duration of pain is around 10 minutes and subsides after taking nitroglycerine

• Dyspnea, Headache, Fatigue

Anamnesis of Disease

• She started to feel this pain in her chest since two days, after some emotional stress, and decided to take professional help.

• She was having dyspnea since last two weeks.• She has been suffering from arterial

hypertension since last 10 years.• She also have diabetes mellitus type 2 since

last 7 years.

Anamnesis of disease (Contd.)

• Never had any severe ischemic heart disease like myocardial infarction or stroke earlier.

• Under medication for hypertension – enalapril, and captopres sublingually in case of sudden rise of blood preassure.

• Also under anti diabetic medicine.

Anamnesis of Life

• She has only 4 members in her family. Her son and his family stays with her. In recent times she is not in good terms with her son, and that is the reason of her emotional stress, hence leading to her condition.

General Status

• General condition: Normal• Skin: Pale, decrease of skin turgor• Auscultation of heart: Regular, without

pathology, accentuation of second heart sound near aorta.

• Heart rate: 84 bpm• Pulse: 84 bpm• Blood pressure: 160/100 mmHg

Preliminary Diagnosis

Ischemic Heart Disease

Plan of Examination

• Complete blood test• Biochemical blood test• Coagulation test• Urine test• ECG• Blood test for Troponin I

Complete blood count

Biochemical blood test

Coagulation test

Urine test

Urine test (Contd.)

ECG day 1 (12/01/15)

ECG day 1 (Contd.)

ECG interpretation

• Sinus rhythm• Heart rate: 72 bpm• Regular• ST depression in leads V1 V2 V3 V4 V5 V6

• Hypertrophy of left ventricles

ECG day 2 (13/01/15) after medicine

ECG day 2 (Contd.)

ECG interpretation

• Sinus rhythm• Regular• Heart rate: 71 bpm• ST on isoelectric line

Blood test for Troponin I

Final Diagnosis

• Ischemic heart disease – Angina Pectoris, unstable, destabilization from 11/01/2015.

• Diffused Cardiosclerosis• Heart Failure IIA, functional class III• Arterial Hypertension, stage II, degree II• Diabetes Mellitus type 2

Treatment

• CLEXAN 0.4 2t/d for first 3 days, followed by 0.2 2t/d for next 2 days (LMW Heparin)

• LOSPIRIN 75 mg po 1t/d in evening (NSAID)• MONONITROSIDE po 10 mg 3t/d (Nitrate)• ETSET 20mg 1t/d in evening (Statin)• METOPROLOL 25 mg po 2t/d (Beta blocker)• EOSINOPRIL 5 mg po 2t/d (ACE blocker)• TICAGRELOR 90 mg po 1t/d (Cardiomagnil)• TRIFAS 5 mg po ½ tablet in the morning (Diuretic)• METFORMIN 50 mg po 1t/d in the morning (Anti diabetic)• HYDAZEPAM 2 mg po 2t/d (Sedative)• ARMADIN 2.0 injection iv 1t/d• Neuropathological consultation

Neuropathological consultation

Asthenoneuropathic syndrome

THANK

YOU

SO

MUCH