G

1.  IDENTIFICATION  DATE OF ADMISSION  19/01/2016
 Age  25
 SEX  M
 MRN  704560
 Address
 Admission
Diagnosis
 Killip class II STEMI
HU CHMS SOM Dpt of Internal medicine 1
Case 1
10/5/2023

2. Subjective Evidence
HPI
 This is a 25 year old male Pt presented with squeezing, heavy
type of chest pain which radiate to left shoulder and back of
1 day duration.
 Associated with this he has hx of diaphoresis, SOB and
vomiting of the same duration.
 The pain started while he was awaking from sleep at
morning.
 He has hx smoking for the past 5 years which is half pack per
day ( 2.5 pack year)
 Other wise he has no hx of flank pain
no cough or fever
no hx loc ABM
2
10/5/2023

3. Objective Evidence
HU CHMS SOM Dpt of Internal medicine
3
PHY EXAM
RS
 Crepitation over 1/3 chest
posteriorly
 Decreased air entry over
the same area
MSS/
IGS
 No deformity
 No edema
GA stable
Vital signs
BP 111/74mmHg
PR 99 BPM
CVS
 There is grade III HSM
at apex
RR 24 BPM
T 37.0 po2 95%
off
HEENT
ABD
GUS
 Flat and moves with
respiration, no palpable
organomegally, no sign
of fluid collection.
• No CVAT
Pink conjunctiva ,NIS,
CNS  COTPP GCS 15/15
LGS  No LAP
10/5/2023

4. Complete blood count Clinical Chemistry
Test Item Result Ref Range Test Item Result Ref range
WBC 8.2X10^3 4.0-11x103/L FBS/RBS 75-100 mg/dl
RBC 4.0-5.6X1012/L Creatinine 1.1 0.5-1.2 mg/dl
HCT 37 36-46% ALP 203 13-43 mg/dl
HGB 14 12-16g/dl SGOT 469 12-38 U/L
MCV 85 80-100fl SGPT 161 7-41 U/L
MCHC 32 32-36g/dl Blood Grp& RH Result Cardiac troponin
> 50
RDW 12 <14.5% Blood type
Platelets 351 X10^3 <150-450x10-9/L Blood film
ESR 0-20mm/hr PERIPHERAL
morphology
Urine Analysis Na 136
K 3.63
Cl 97.2
TIMI SCORE=2
SPGR
PH
ALBUMIN
GLUCOSE
KETONE HU CHMS SOM Dpt of Internal medicine 4
10/5/2023

5. IMAGINGS
10/5/2023 HU CHMS SOM Dpt of Internal medicine 5

6. 10/5/2023 HU CHMS SOM Dpt of Internal medicine 6

7. What was done
 Lasix 40mg iv tid
 ASA 81mg po daily
 Clopidogrel 75 po daily
 Atovastatin 80mg po daily
 UFH 17500iu sc bid
 Morphine 4mg iv qid
 Omeprazole 20mg po bid
 Bisacodyl 5mg po daily
 Follow v/s and uop
HU CHMS SOM Dpt of Internal medicine 7
10/5/2023

8. PLAN
 Continue The management
 Update Ix
 Follow v/s
 Hba1c, lipid & coagulation profile
HU CHMS SOM Dpt of Internal medicine 8
10/5/2023