A 55 Year Old Hypertensive Woman With Delayed Presentation of Acute Myocardial Infarction

A 55-year-old woman with a history of hypertension and hypothyroidism had admitted to the coronary care unit with complaints of central heavy chest pain for two days. She had remained untreated before the admission. She was found to have an anteroseptal myocardial infarction confirmed by troponin I and serial ECGs which are attached below.

Her vitals at the presentation were: blood pressure 160/100 mmHg, pulse 80 beats/min, normal temperature. Her initial troponin I was 7.56 ng/ml. Her hemoglobin% was 15.23 gm/dl, total leucocyte count 10,600 per microliter with 78% neutrophil, ESR 30 mm. Her lipid profile was: total cholesterol 192 mg/dl, HDL 46 mg/dl, LDL 116 mg/dl, TG 154 mg/dl. Her thyroid profile was normal on 50 mcg of thyroxine. Her serum creatinine was 0.91 mg/dl. Her RBS was 110 mg/dl, FBS 125 mg/dl, PPBS 150 mg/dl. Her HbA1C was 7.6%. Her USG whole abdomen was found to have mild hepatomegaly with fatty liver change.

She could not be given thrombolysis as she was out of the window period. She has been treated with enoxaparin 80 mg (BD) for 7 days. She has been started on dual antiplatelet (aspirin 75mg + clopidogrel 75mg), atorvastatin 20mg, olmesartan 20mg (previously taking), metoprolol 25mg (previously taking), nitroglycerine, trimetazidine 35 mg. Her repeat troponin I on the 6th day was 0.01 ng/dl.

Her husband and son who were getting treatment in India while she stressfully staying back at home alone without appropriate attention to her antihypertensives and dietary care. She had been having stable angina for quite a year; however, her TMT was reported negative 8 months back. She has a parental (father) history of premature death due to the acute coronary syndrome. Her brother has had stable angina for which he got stented after coronary angiogram a few years back. Right now after discharge, she looks clinically stable with two instances of exertional chest discomfort after the discharge.

ECG AT PRESENTATION

ECG ON DAY 1

ECG ON DAY 2

ECG ON DAY 3

ECG ON DAY 4

ECG ON DAY 5

ECG ON DAY 6

ECG ON DAY 7

ECHO 1

ECHO 2

ECHO 3

ECHO 4

DISCHARGE SUMMARY 1

DISCHARGE SUMMARY 2

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55 years Old male with Bipolar affected disorder moving from depression to Manic to depression phase

Disclaimer:- This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here December 2017 after collecting informed patient consent (form downloadable Click Here) This is a case of a 55 years old, diabetic, hypertensive patient who was diagnosed with Bipolar affected disorder since 1995. In 1995 due to financial loss he was attacked by this condition. He was seen by Dr. D. K Agarwala and diagnosed as BPAD-Depression phase and treated with lithium, sodium valporate, propranolol, Zeptol cr, Nitrosum - S. With the treatment he was reasonably well but every 6 months of interval he appeared to have some disturbance like didn't want to talk to anybody, forgot to smile etc. They went to the doctor and treated accordingly and was continuing the treatment. In the year of 2013, August he was diagnosed with BPAD-severe depression phase but, he was not responding well to the medications and then they went to NIMHANS for

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drugs to avoid or use in terms of their pregnancy category

The optimal AEDs therapy of women with epilepsy who are of childbearing age is unclear because of a lack of conclusive data on the comparative teratogenicity of different antiseizure drugs and no antiepileptic drug has proven safe in pregnancy in terms of teratogenesis. Data on the comparative efficacy of various antiseizure drugs for controlling seizures during pregnancy are also quite limited, and there are no randomized trials in this setting. Treatment must be individualized for all patients. Women with epilepsy are classified as high risk during pregnancy and as there are no clear data indicating that any drug is without risk in pregnancy therefore, the antiseizure drug regimen should be optimized six months prior to planned conception. Choice of antiepileptic drugs in women of childbearing age and pregnant women with epilepsy: 1. T he antiseizure drug that stops seizures in a given patient is the one that should be used with an exception of valproate. 2.

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