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![ 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]](https://image.slidesharecdn.com/4-230801104852-c5d4eee2/75/4-Ischemic-Heart-Disease-with-Hypertension-Dr-Fatema-pptx-5-2048.jpg)
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4. Ischemic Heart Disease with Hypertension-Dr.Fatema.pptx
- 1. Ischemic Heart Diseasewith Hypertension Speaker : Dr. Fatema Khanbhaiwala 3rd year M.D. Anaesthesiology Resident Narendra Modi Medical College and Sheth L.G. Hospital
- 2. Case Presentation PatientDetails 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 A74 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 wasrelatively 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 isa 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 Patienthad 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 similarcomplaints 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.
- 8. Family History Patient’sfather was having hypertension and ischemic heart disease.
- 9. Drug / AllergyHistory No allergic history
- 10. Personal History Onmixed 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 Aftertaking 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 anysigns of jaundice, anemia, cyanosis, clubbing, oedema or lymphadenopathy. No neck vein engorgement. No any skeletal or muscular deformity.
- 14. Airway Assessment andspine 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 Atpresent, 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 shapedprecordium 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 wouldlike 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 noteof 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 insupine 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 localrise 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 tympanicnote 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.
- 23. Auscultation Normal peristalsisheard. No audible bruit.
- 24. R.S. Upper respiratorytract 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 isconscious, 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 74years 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.
- 27. Preoperative investigations available Hb- 12.1 gm/dl TLC – 13,400 cells/ul APC – 2.14 lacs PT/INR – 13.4/1.7 Sr. Creatinine – 1.053 Urea – 18 Serum electrolytes – Na+ - 134, K+ - 4.6, Cl- - 107 Sr. bilirubin – 1.2 SGPT – 56 ALP – 110 RBS – 110 mg/dl CXR – NAD ECG – WNL/NSR USG – 12 mm inflamed appendix with minimal fluid collection in RIF.
- 28. Provisional diagnosis 74years 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.