09-10-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[09-10-2025 21.22] PPM 1: https://youtube.com/shorts/o1HgR8AdF9o?si=V7S-xyss_CClKFEp
Angiography notes
Text of his EMR summary 👇
Age/Gender: 56 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 09/10/2025 12:04 PM
Name of Treating Faculty
(CARDIOLOGIST)
(SR)
Diagnosis
K/C/O CAD-ANTERIOR WALL MI S/P PTCA 8 YRS AGO
MILD LV DYSFUNCTION
K/C/O T2DMV SINCE 2 MONTHS
Case History and Clinical Findings
PATIENT CAME WITH CHEIF COMPLAINS OF CHEST PAIN SINCE 6 MONTHS AND SOB ON
EXCERTION SINCE 6 MONTHS
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS BACK THAN HE DEVLOPED
CHEST PAIN AND SOB WHICH WAS INSIDIOUS IN ONSET, PROGRESSIVE, AGGREVATED
ON EXCERTION HISTORY OF PALPITATION PRESENT WHICH IS INTERMITENT.
K/C/O CAD AWMI S/P PTCA SINCE 8 YEARS
KNOWN CASE OF DIABETS MELLITUS SINCE 2 MONTHS AND ON TAB.METFORMIN 500 MG
+GLIMIPRIDE 1MG PO OD, N/K/C/O HTN, CVA, THYROID, EPILEPSY
GENERAL EXAMINATION-TEMP: AFEBRILE, BP:120/70MMHG, RR:18CPM, PR:70
BPM, SPO2:98% AT RA
SYSTEMIC EXAMINATION:CVS-S1 S2 +, NO MURMUR, RS-BAE +, NVBS HEARD, PA-SOFT NON TENDER
CNS EXAMINATION: -TONE- NORMAL IN BOTH RIGHT AND LEFT UPPER AND LOWE LIMBS.
POWER- 5/5 IN RIGHT UPPER AND LOWER LIMB AND 5/5 IN LEFT UPPER AND LOWER LIMB.
REFLEXES: - RIGHT-BICEPS- +2; TRICEPS- +2; SUPINATOR- +1; KNEE- +2; ANKLE- +1;
PLANTAR- F
LEFT-BICEPS- +2; TRICEPS- +2; SUPINATOR- +1; KNEE- +2; ANKLE- +1; PLANTAR- F
** Tentative Date Page-2
KIMS HOSPITALS
SENSORY SYSTEM-INTACT
CAG NOTES:
RRA, 6Fr SHEATH, INJECTION HEPARIN 2500U
LMCA-NORMAL, LAD: TYPE 3 VESSEL PROXIMAL PATENT STENT WITH MILD ISR, MID LAD 70% STENOSIS, DISTAL NORMAL, DIAGONAL NORMAL
LCX- DOMINANT NORMAL VESSEL, OMS-NORMAL, LPDA, PLVB-NORMAL
RCA-NON-DOMINANT, PROXIMAL LESION OF 90% STENOSIS, DISTAL -NORMAL
FINAL DIAGNOSIS-CAD-DVD(LAD&RCA)
ADVICE: MEDICAL MANAGEMENT
Investigation
HEMOGRAM- HB-13.8G/DL; PCV-39.1VOL%; TLC-10300CELLS/MM3; RBC-4.8 MILLION/MM3.
PLATELET COUNT-2.8LAKH/MM3
HEMATOLOGY IG 0.13% ABSOLUTE EOSINOPHIL COUNT 0.45 CELLS/MCL
ABSOLUTE LYMPHOCYTE COUNT 303010^3/UL ABSOLUTE NEUTROPHIL COUNT 5.85 10^3/UL
ABSOLUTE MONOCYTE COUNT 0.70 10^3/UL ABSOLUTE BASOPHIL COUNT 0.3 10^3/UL
HIV -NEGATIVE; HBSAG -NEGATIVE; HCV-NEGATIVE.
SERUM CREATININE 0.9 MG/DL
Treatment Given (Enter only Generic Name)
TAB CLOPITAB-A 150 MG PO OD AT 2 PM
TAB AZTOR 80 MG-1 TABLET PO OD AT 9 PM
TAB CONCOR 2.5 MG PO OD AT 9 AM
TAB NICORANDIL 10 MG PO BD 9 AM - 9 PM
TAB FLAVEDON OD 80 MG PO OD AT 9 AM
TAB PANTOCID 40 MG PO OD AT 7 AM
Advice at Discharge
TAB CLOPITAB-A 150 MG PO OD AT 2 PM TO BE CONTINUED
TAB AZTOR 80 MG-1 TABLET PO OD AT 9 PMTO BE CONTINUED
TAB CONCOR 2.5 MG PO OD AT 9 PMTO BE CONTINUED
TAB NICORANDIL 10 MG PO BD 9 AM - 9 PMTO BE CONTINUED
TAB FLAVEDON OD 80 MG PO OD AT 9 AMTO BE CONTINUED
TAB PANTOCID 40 MG PO OD AT 7AM FOR 10 DAYS
Follow Up
REVIEW TO CARDIOLOGY OPD AFTER 10 DAYS/SOS
** Tentative Date Page-3
KIMS HOSPITALS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
For Treatment Enquiries Patient/Attendant Declaration: - The medicines prescribed
and the advice regarding preventive aspects of care, when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:10/10/25 Ward: ICU Unit: 4
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