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CASE STUDY

(The patients name has been changed for


confidentiality purpose. )
Patients name : XYZ
Age: 53
Sex : male
Phone no. :9000258621
Addiction: smoking.
Complaints of:
1.Severe chest pain.

2. Acute breathlessness(3 days)


Past History
History of acute myocardial infarction in year
2009.
Patient was thrombolised with Tenactoplase .
On admission patient was found to be
hypertensive. Patient was subjected to
Angiography. Later on his arteries was found
to be normal (good result of thrombolysis).
Patient was prescribe anti hypertensive
drugs, coronary dilators and antiplatelet.
History of present illness

Patient developed sudden chest pain and


breathlessness 15 days back. Looking into
his past history ECG was done which showed
echmic changes. Thereafter the coronary
artery was found to show blockage . He was
advised angiography /stenting.
Clinical summary: Mr. XYZ is a case of
hypertension IHD(old IWMI- thrombolyzed in
2009) with Non Critical coronary Artery
Disease (CAG done in 2009) with Exertional
Angina (TMT +ve) with normal LV Function,
was admitted for coronary angiography.
Coronary Angiography was done which
showed single vessel with mild Stenosis of
LAD. Hence he is advised PTCA to OM1 and
distal LCx. Patient remained stable
throughout hospitalization and is being
discharged in stable condition.
Clinical Diagnosis: Hypertension with IHD(Old
IMWI-thrombolysed in 2009) with non critical
coronary artery disease (CAG done in 2009)
with exertional angina (TMT +ve) with single
vessel disease with normal LV function (LVEF
65%)

Procedure performed: Coronary Angiography


-right radial route.
Date of procedure: 24-10-16
Comments: Pathology reports allotted along
with discharge card.

Investigtions:
1.
ECG done regularly.
2.
HBA1C-5.6
3.
Serum potassium-4.2
4.
Serum sodium:139
5.
Serum creatinine:1.12
6.
Blood urea:21
7.
Triglyceride : 169
8.
VLDL:33.80
9. LDL:40.20
10.
Cholesterol:113
11.
Hemoglobin: 13.5
12.
Blood sugar fasting:102
Treatment advised:
DRUG GENERIC
NAME NAME

DOS
ES

TIMIN DURATI
G
ON

Mono
isodri
l

1-00

8 AM

Isosorbid
e
mononitr

To cont.

ate
Carda Ramipril
ce
5mg

1-00

7 AM

To cont.

Conco Bisopropl
r
ol

0-01

9 AM

To cont.

Rosed Rosuvast
ay
atin+
gold
aspirin
10mg

0-01

AD

To cont.

Nikorandil 0-01

AD

To cont.

K-cor
10

Condition at discharge:Afeb, pulse80/min,BP-130/80mm Hg, Chest-clear, CVsS1,S2(n)


Final diagnosis: Single vessel Disease with
moderate Stenosis of LAD (40%)
Advice: PTCA to OM1 and Distal LCx.

Coronary Angioplasty report


Patient name: XYZ
Procedure date: 2-11-16
Age: 53 years
Sex: male
Performed by: Dr. H.M. Mardikar and Dr. N.V.
Deshpande
Clinical findings: PR-60/mt Reg, BP-157/94
mm Hg CVS: S1S2 (N) Chest: Clear
Abdomen- NAD
Diagnosis: Single vessel disease with
moderate Stenosis of LAD
Remarks: PTCA to LAD and LCx was done
with 01 Pronova XR and 01 Eucatech AG DES
Implantation with Inj. Tirofibnan.

1. Artery:LAD
LAD: Mid segment has 40% eccentric and
discrete tenosis. 22mm in length and 3.0
mm diameter type B2 TIMI-/III flow.
Stent: Eucatech AG 2.75 in diameter and
28mm long was deployed at a pressure
12mm the indication for stenting was
denovo.
2. Artery: LCx
LCx: Proximal segment hs 80% eccentric
and discrete stenosis. 18mm in length and
2.75 diameter. Type B2 TIMI-III flow
Stent : Pronovo XR 2.50 in diameter and
23mm long was deployed at a pressure
122mm the indication for stenting was
Denovo.
Guide Catheter: 7f, JR 4 guide catheter
was used.
Result: procedure was successful.