4. Ischemic Heart Disease with Hypertension-Dr.Fatema.pptx
1. Ischemic Heart Disease with
Hypertension
Speaker : Dr. Fatema Khanbhaiwala
3rd year M.D. Anaesthesiology Resident
Narendra Modi Medical College and Sheth L.G. Hospital
2. Case Presentation
Patient Details
Name - Nanjibhai
Age - 74
Sex – Male
Weight – 80 kg
Height – 168cm
BMI – 28.34
Residence – Gujarat
Religion – Hindu
Occupation – Autodriver
Socio economical Class – Lower
3. Chief Complaint
A 74 years old male Patient came to L.G. Hospital on 20th February 2023 with chief
complaints of
Abdominal pain – 2 days
Nausea – 2 days
Vomiting – 1 day
Fever – 1 day
4. ODP
Patient was relatively asymptomatic before 2 days.
Then he developed abdominal pain which was sudden in onset, started at
periumbilical region and radiated towards right iliac fossa and increased in
intensity while walking.
Pain was associated with nausea since 2 days and vomiting since 1 day, 2-3
episodes of vomiting since 1 day which was yellow in colour, non projectile,
containing food particles, vomitus didn’t contain blood or coffee coloured content
and not associated with headache or food intake and low grade fever.
5. Patient is a known case of Hypertension and Ischemic heart disease since 7
months and he is on following treatment.
Patient came with treatment card and drugs.
T. Aspirin (150) [0-1-0]
T. Clopidogrel (75) [0-1-0]
T. Atorvastatin (40) [0-0-1]
T. metoprolol (25) [1-0-1]
T. NTG (2.6) [1-0-1]
6. Past History
Patient had history of chest pain which was sudden in onset and of squeezing type,
radiating towards left arm and left jaw,
Associated with palpitations and shortness of breath, perspiration
Not relieved by rest
Not associated - giddiness, dizziness, loss of consciousness, muscle weakness in limbs,
decreased urine output, oedema over bilateral lower limbs, was not associated with
cough with expectoration, pink frothy sputum, cold periphery,
Hospitalized for the same and some investigations were done.
At that time he was diagnosed with Acute Coronary Syndrome for which he
underwent Coronary Angiography.
Which was suggestive of single vessel disease with 80% stenosis in LAD and it was
treated medically.
7. No similar complaints in past.
No history of other systemic illness like DM, bronchial asthma, T.B. , jaundice.
No history of trauma, blood transfusion.
Patient had no surgical history in past.
10. Personal History
On mixed vegetarian diet with decreased appetite
unaltered bowel and bladder habit with adequate sleep.
Chronic tobacco chewer since 30 years.
No other addictions like smoking or alcohol at present.
11. General Examination
After taking consent, I have examined the patient in proper light and exposure and
in sitting position.
Patient is conscious, oriented to time, place and person and co-operative and
following verbal command.
Well nourished
moderately built.
Height -168 cm
Weight - 80 kg
BMI of 28.34 kg/m²
12. Temperature – normal on touch
Pulse – 88/min in sitting position in right radial artery, Regular rate rhythm, Normal
force, volume, tension, No radioradial or radiofemoral delay.
BP – 136/80mmHg in right brachial artery in sitting position and auscultatory
method.
Spo2 – 97% on room air
Respiratory rate – 16-18 / min – abdomino thoracic type
Breath holding time – 22 seconds
E.T. – fair
Patient is able to walk fast
Climbs 2 flight of stairs
METS score – 5-6 METS
13. No any signs of jaundice, anemia, cyanosis, clubbing, oedema or
lymphadenopathy.
No neck vein engorgement.
No any skeletal or muscular deformity.
14. Airway Assessment and spine examination
M.P. grade – 2
Mouth opening – 3 fingers
Neck flexion – adequate
Neck extension – adequate
TMD – 6.5 cm
Teeth – all present, no artificial or loose tooth, staining present
Spine – Normal
15. Systemic Examination
At present, as patient is having complaints of abdominal pain and vomiting, I
would examine GIT system but as patient had complaints of chest pain and
palpitations in past and patient is on antihypertensives, antiplatelets,
anticoagulants, I would like to examine CVS first.
I have examined patient in semi reclining position in proper light and exposure.
16. Inspection
Normal shaped precordium
Overlying skin normal
Chest size and shape normal
Apex impulse – 5th IC space, 2 cm inside midclavicular line.
No visible pulsations, bulging or dilated veins seen
No scars or sinuses
17. Palpation
I would like to confirm my inspectory findings by palpation.
Temperature – normal
Apex beat – left 5th IC space, 2 cm inside mid clavicular line located by pulp of
index fingers
Carotid artery pulsations are raised in right and left side
No other palpable sound over precordium.
18. Percussion
Dull note of left heart border is felt at left 3rd , 4th and 5th ICS 4cm, 7cm and 9cm
away from midsternal line
Liver dullness in right 5th , 7th and 9th ICS in midclavicular, midaxillary and scapular
line respectively
19. Auscultation
Done in supine position
S1 S2 heard over Mitral, Tricuspid, Aortic and Pulmonary area.
No murmur or any foreign sounds.
20. GIT
Inspection
Abdomen – globular
Moving regularly with respiration
Umbilicus – centrally placed, inverted,
normal
No venous distention
No abdominal distention
Back and spine normal
No sinuses or scars
No visible peristalsis or pulsations
No scrotal swelling
21. palpation
No local rise in temperature
Tenderness in RIF at Mc burney’s
point.
Best elicited in left lateral position.
Localized rigidity and guarding over
RIF.
Liver , spleen, kidney non palpable
No lump
No expansile impulse on cough
impulse at hernial sites.
No renal angle tenderness.
Both testes are in scrotum, normal
size and consistency.
Testicular sensation present.
22. Percussion
normal tympanic note
Upper border of liver dullness in right 7th ICS in midclavicular line, 8 finger breadth
below costal margin in mid clavicular line & 2 finger breadth lateral to umbilicus.
24. R.S.
Upper respiratory tract normal
Shape of chest normal with bilateral equal movement.
Normal bilateral vesicular sound present
Abdomino thoracic breathing type
RR – 16-18/min
Trachea centrally placed
25. C.N.S.
Patient is conscious, oriented and following verbal commands
GCS -15/15.
Sensations normal in both upper and lower limb.
5/5 power in both upper and lower limbs.
Bowel bladder sensations intact.
26. Probable diagnosis
74 years old male patient, known case of hypertension and
ischemic heart disease since 7 months and on regular
treatment presented with complaints of abdominal pain,
nausea, vomiting and fever since 2 days under investigations.
28. Provisional diagnosis
74 years old male patient known case of hypertension and ischemic heart disease
since 7 months and on regular treatment presented with complaints of abdominal
pain, nausea, vomiting and fever since 2 days, diagnosed with acute appendicitis
from ultrasound sonography of abdomen and posted for emergency open
appendicectomy.