MI

This is an online E log book to discuss our patient\"s de-identified health data shared after taking his/her/guardian\"s signed informed consent. Here we discuss our individual patient\"s problems through series of inputs from available global online community of experts with an aim to solve those patient\"s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment




 A 58 yr old man came with cheif complaints of 

  Giddiness since 3 hrs  

   Vomitings since 2 hrs 

   Loose stools since 2 hrs 

   SOB since 2 hrs approximately 

History of  presenting illness :  

Pt was apparently asymptomatic 3 hrs back  then he developed giddiness 3 hrs back 
Then one episode of vomiting 2 hrs back which is non projectile , non bilious 
Then he had one episode of loose stools 2 hrs back approximately 
SOB since 2 hrs 
No h/o chest pain , palpitations 
No h/o fever , generalized body pains 

Past history: 

No similar complaints in past 
No h/o htn ,DM , CVA , CAD ,TB ,asthma 

Treatment history : 

Not relevant 

Personal history :

Appetite - normal 
Diet mixed
Bowel and bladder regular 
Sleep adequate 
Micturition normal 
Addictions : he smokes ciggarettes since 10 yrs and taking  alcohol since 20 yrs 

Family history : 

Not relevant 

General examination : 

Pt is conscious  coherent and cooperative moderately built and moderately nourished  

No pallor ,icterus,cyanosis,clubbing ,lymphadenopathy ,edema of feet ,dehydration 

Vitals : PR: 110bpm 
            RR :22cpm
            Bp : 90/60mmhg 
            GRBS : 237
            Afebrile 

Systemic examination : 

CVS: s1 and s2 heard 
         No added thrills and murmurs 

RS : dyspnea present 
        No wheeze 
         Position of trachea central 
         Vesicular breath sounds heard 

Per abdomen : soft non tender , no organomegaly 

CNS :  intact 

Provisional diagnosis : 

                          ANTEROLATERAL MI  

Investigations :

 ECG 



Treatment: 

1) inj STREPTOKINASE 1.5million IU(iv/ over 30 mints ) 
2) TAB. ASPIRIN 305 mg po / stat 
3)TAB ATORVASTATIN80 mg po / stat 
4) TAB CLOPIDOGREL 300mg po/ stat 
5) TAB SORBITRAT 5 mg po / stat 
6) o2 inhalation /sos 
7) inj.ZOFER 4mg iv/ stat 
8) bp ,PR spo2. Monitoring









 


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