65F ACS VT S/P DCCV SAH SDH

 

Diagnosis :

     CAD: Effort Angina

     TMT - Positive

     S/P CAG - SVD

     S/P PTCA stent to LAD

     VT Episode -- DCCV --> NSR

     S/P Mechanical ventilation (Extubated on 26.10.26)

     Diffuse SAH / SDH

 

Past Medical History :

     Non obstructive HCM

 

Chief Complaints :

Mrs. xxxxx, aged 65 years old female, known case of non obstructive HCM, TMT - Positive, S/P Adhoc PTCA to LAD with 2 DES [24.10.26], 2 VT episodes during angioplasty (150 - 200 J DC shock delivered) --> Sinus rhythm, she was intubated and put on mechanical ventilation and started on Vasopressors / anti arrhytmias, Post procedure CT Brain done showed diffuse SAH parieto occipital region with minimal SAH in Rt. frontal. Thin SDH measuring 2-3mm along with paramedian infarct anteriorly and posteriorly, CT KUB : B/L Small kidneys with cortical scars, MRI Brain and Venogram done, no active surgical intervention, she was referred back to DDH.

 

General Examination :

       Patient Conscious / Coherent :

       No Pallor , No Icterus , No Clubbing , No Edema , No Cynosis :

       Pulse Rate : 80 / Min

       Temperature : 98.4

       Blood Pressure : 100/70 mmHg

       Respiratory Rate : 20 / Min

       Saturation : On Mechanical ventilator support

 

Systemic Examination

     CVS [ S1 , S2 PRESENT ] , Resp. System [ BAE +, B/L Crepts+ ] , Abdomen [ SOFT, BS + ] , CNS [ NAD, GCS, 15 / 15 ]

 

Course In the Hospital :

Mrs. xxxx, aged 65 years old female, got admitted with the above mentioned complaints to the hospital. She was treated with IV antiepileptic, antibiotics, antiplatelets, statins and other supportive medications. Routine investigations done. Patient had 2 episodes of VT, S/P DCCV - NSR. In view of low GCS, Neurophysician consultation done and diagnosed as Mild SAH with SDH (No neurological deficits) and treated accordingly. In view of elevated SGOT& SGPT, Medical Gastroenterologist consultation done and advice followed. Repeat CT Brain showed Resolving SAH and SDH, No mass effect, Neurophysician review done and advice followed. In view of non obstructive HCM, H/o Hematuria, Urologist consultation done and treated accordingly. In view of HB - 7.7 gm/dl, 1 unit of PRBC was transfused. Patient was stable at the time of discharge. She was discharged on the following medications and advises. Long term prognosis was explained in detail.

 

Investigations : Cummulative Report

 

Date	29-10- 2026 10:30	28-10- 2026 09:52	27-10- 2026 10:37			Units	Reference
Haemoglobin	11.7	12.0	7.7*			g%	11 - 16
RBC Count	3.9*	4.0	2.5*			x10^6/ul	4 - 5.2
Total WBC Count	8400	11300*	13300*			cells/cumm	4000 - 11000
Platelet Count	1.58	1.45*	1.42*			Lakhs/cum m	1.5 - 4.5
Packed Cell Volume (PCV)	34.3*	35.0*	22.5*			%	36 - 46
Mean Corpuscular Haemoglobin (MCV)	86.8	86.7	87.8			fl	70 - 100
Mean Corpuscular Heamoglobin(MCH)	29.6	29.8	29.9			pg	27 - 32

 

MeanCorpuscular Heamoglobin Concetration(MCHC)	34.1	34.3	34.0			g/dl	32 - 36
RDW	13.4	13.7	14.0			%	11.6 - 14
Granulocytes	80*	85*	90*			%	40 - 75
Lymphocytes	15*	10*	05*			%	20 - 40
Eosinophils	03	03	03			%	0 - 6
Monocytes	02	02	02			%	2 - 10
Basophils	00	00	00			%	0 - 1
Date	28-10- 2026 09:52	27-10- 2026 10:37	26-10- 2026 19:55	26-10- 2026 16:56	24-10- 2026 17:00	Units	Reference
Sodium	139	150*	149*	147*	144	mmol/L	135 - 145
Potassium	3.5	3.9	4.6	4.1	3.0*	mmol/L	3.5 - 5.1
Calcium	1.21	1.30	1.14	1.20	1.08*	mmol/L	1.13 - 1.32
Creatinine	0.80	1.0	1.7*	1.5*	0.90	mg/dl	0.6 - 1.2
Blood Urea	53*	68*	60*	95*	29	mg/dl	10 - 45
Egfr	33					ml/min/1.73 m2
Date	27-10- 2026 10:37	24-10- 2026 17:00				Units	Reference
Total Bilirubin	0.70	0.33				mg/dl	0.3 - 1.2
Direct Bilirubin	0.30	0.15				mg/dl	0 - 0.4
SGOT	442*	120*				U/L	0 - 31
SGPT	115*	95*				U/L	0 - 35
Alkaline Phosphatase	118	111				U/L	108 - 306
Total Protein	4.9*	6.3				g/dl	6 - 8
Albumin	2.5*	3.5				g/dl	3.5 - 5.2
Globulin	2.4*	2.8				g/dl	2.5 - 3.5
A:G Ratio	1.04	1.25				%	1 - 2.1
Date	27-10- 2026	26-10- 2026	24-10- 2026			Units	Reference

 

	10:37	19:57	20:05
Test	20.1*	19.0*	20.0*			Seconds	13 - 17
Control	12.0	12.0	12.0			Seconds
INR	1.7	1.6	1.7			-

 

Discharge Medication

 

Order Date	Drug Name	Dose	Route	Frequency	Duration	Remark
29-10-2026 01:48 PM	TAB ECOSPRIN 75MG	75 mg	ORAL	Once Daily(OD)	daily	2PM AFTER FOOD
29-10-2026 01:48 PM	TAB BRONAC 600 MG	600 mg	ORAL	BD(TWICE DAILY)	daily	8AM - 8PM AFTER FOOD
29-10-2026 01:48 PM	TAB PAN 40MG	40 mg	ORAL	Once Daily(OD)	daily	7AM BEFORE BREAKFAST
29-10-2026 01:48 PM	TAB ALDACTONE 25MG	25 mg	ORAL	Once Daily(OD)	daily	2PM AFTER FOOD
29-10-2026 01:48 PM	TAB NIKORAN 5 MG	5 mg	ORAL	BD(TWICE DAILY)	daily	8AM - 8PM AFTER FOOD
29-10-2026 01:48 PM	TAB NODOSIS	1 gm	ORAL	TID(THRICE DAILY)	daily	8AM - 2PM - 8PM AFTER FOOD
29-10-2026 01:48 PM	TAB CLOPITAB 75MG	75 mg	ORAL	Once Daily(OD)	daily	2PM AFTER FOOD
29-10-2026 01:48 PM	TAB LEVIPIL 500MG	500 mg	ORAL	BD(TWICE DAILY)	daily	8AM - 8PM AFTER FOOD

 

Condition at Discharge :

     Patient Conscious / Coherent

     No Pallor , No Icterus , No Clubbing , No Edema , No Cynosis

     Pulse Rate : 80 / Min

     Temperature : 98.4

     Blood Pressure : 100/70 mmHg

     Respiratory Rate : 20 / Min

     Saturation : 98 % On Room Air