This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here after collecting informed patient consent (form downloadable Click Here) by BMJ Elective Student.
The patient is a 59-year-old male who had angina-like chest pain during July 2017 characterizing as “chest burn” and “”mild pressure-like sensation” while walking in the morning on his way to the office. His daughter, who is a medical student, thought of taking him to a cardiologist and performed an ECG and chest x-ray which revealed a cardiomegaly. The cardiologist did ECHO on him and told that has mitral valve regurgitation which was of little concern that time and advised a coronary angiogram (CAG). (Past reports are attached) On the next day, he was taken for a CAG which revealed two blocks (single vessel disease; LCX and LMCA normal; LAD- proximally 30% stenosis; RCA- proximally 60-70% stenosis, PLB 70-80% stenosis at mid part) and then without advising PCI prescribed some medications (listed below). He had liver abscess diagnosed in 2006. He also has bronchial asthma, hypertension and diabetes mellitus.
The patient is a 59-year-old male who had angina-like chest pain during July 2017 characterizing as “chest burn” and “”mild pressure-like sensation” while walking in the morning on his way to the office. His daughter, who is a medical student, thought of taking him to a cardiologist and performed an ECG and chest x-ray which revealed a cardiomegaly. The cardiologist did ECHO on him and told that has mitral valve regurgitation which was of little concern that time and advised a coronary angiogram (CAG). (Past reports are attached) On the next day, he was taken for a CAG which revealed two blocks (single vessel disease; LCX and LMCA normal; LAD- proximally 30% stenosis; RCA- proximally 60-70% stenosis, PLB 70-80% stenosis at mid part) and then without advising PCI prescribed some medications (listed below). He had liver abscess diagnosed in 2006. He also has bronchial asthma, hypertension and diabetes mellitus.
He had been under follow-up for a while until recently he is taken to an interventional cardiologist for a follow-up. He does not feel chest discomfort at rest, however, gets occasional chest discomfort which is only during walking (mostly in the morning) for some distance (5-10 minutes). This time doctor did another ECHO and ECG found severe mitral regurgitation (grade IV) and advised CABG and MVR (current reports are attached) and prescribed new medications (listed below).
Medications list from 2017:
- Losartan Potassium + Hydrochlorothiazide (Once daily after lunch)
- Doxofylline 200 mg (once daily)
- Trimetazidine mg (twice daily)
- Pantoprazole 40 mg (twice daily)
- Losartan potassium 50 mg (once at night)
- Salmeterol and fluticasone (25/250)
- Salbutamol (as needed)
Medications list recently prescribed in 2018 (December 1st):
- Aspirin 75 mg (once at night)
- Nitrates (twice daily)
- Furosemide 40 (once in the morning)
- Telmisartan 40 (once at night)
- Atorvastatin 20 (once at night)
2017 reports:
- Chest x-ray: cardiomegaly and enlarged both hiler shadows
- CAG (attached)
- ECHO report (attached)
2018 reports:
- ECHO report (attached)
- New prescription (attached)
Recent prescription from an interventional cardiologist
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ECHO report part 1 performed in December 2018 |
Schematic of the CAG performed in 2017
Old ECHO (part 1) performed in 2017 showing grade III MR
Old ECHO (part 2) performed in 2017 showing grade III MR
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