Discharge Summary ANSAR MEHMOOD GHULAM KAUSAR-HC03049234
*Final Report
* Final Report *
Date of Admission:
02/05/24
Date of Discharge:
13/05/24
Principal Diagnosis:
Non-ST elevation Myocardial infarction
Other diagnosis:
type 2 diabetes.
Reason for Admission:
Chest pain
Significant
Last Month
Findings:
Basic Metabolic Panel: Hematology:
: () Hgb: 15.1 gm/dL (13/05/24)
Potassium Level: 4.2 mmol/L (13/05/24) ()
:) WBC: 7.6 x10^3/uL (13/05/24)
()
BUN: INR: 1.5 (13/05/24)
Creatinine Level: 107 umol/L (13/05/24)
Additional Last Month
ABO: Group A (07/05/24) |Absolute Neutrophil count Auto# (ANC): Adjusted Calcium: 2.45 mmoyL
3.8 x1043/uL (13/05/24) (02/05/24)
Albumin Lvl: 33 gm/L (13/05/24) Alk Phos: 83 U/L (13/05/24) ALT: 19 U/L (13/05/24)
| Antibody Screening: Negative (07/05/24) APTT: 38.4 seconds (13/05/24) |AST: 20 U/L (13/05/24)
Basophil Auto #: 0.10 x10^3/uL Basophil Auto %: 1.1% (13/05/24) BE Ven-POC: 2.8 mmo/L (02/05/24)
(13/05/24)
BE(Ec) Ven-POC: 3.4 mmol/L (02/05/24)BG Glu Ven-POC: 10.6 mmol/L BG Hct Ven-POC: 55.6 % (02/05/24)
(02/05/24)
BG Lac Ven-POC: 1.40 mmoVL(02/05/24) Bicarbonate: 25 mmol/L (13/05/24) Bilirubin T: 4 umol/L (13/05/24)
Ca++ Ven-POC: 1.18 mmol/L (02/05/24)Calcium: 2.35 mmo/L (02/05/24) Chloride: 101 mmol/L (13/05/24)
Cholesterol: 4.4 mmo/L (03/05/24) CI Ven-POC: 98 mmol/L (02/05/24) COHb Ven-POC: 2.9 % (02/05/24)
COVID-19 Antigen(Manual): Negative CRP: <2.0 mg/L (13/05/24) D-Dimer: 0.63 mg/L FEU (02/05/24)
(03/05/24)
Result type: Discharge Summary
Result date: 13 05, 2024 10:47 AST
Result status: Auth (Verified)
Result title: Discharge HDU B
Performed by: Dr. Fatima Mohamed Sajjadi - 061512 - Medical Resident on 13 05, 2024 10:47 AST
Verified by: Dr. Fatima Mohamed Sajjadi - 061512 - Medical Resident on 13 05, 2024 11:33 AST
Encounter info: 0160475403, HH Heart, Inpatient Acute Care, 02/05/2024 -
Printed by: Noura lsmail -028275- Charge Nurse (CF) -
Accident &Emergency
Printed on: 13/05/2024 12:09 AST Page 1 of 5
ANSAR MEHMOOD GHULAMMKAUSAR
Discharge Summary
Final Report
(13/05/24) Glu -POC: 6.7
Eosinophil Auto %: 4.8 % mmo/L (13/06/nA
Eosinophil Auto #: 0.40 x10^ 3/uL
(03/05/24) HCO3 Ven-POC: 278
(13/05/24) HbAIC %: 8.1 %
Glucose: 11.6 mmol/L (02/05/24) HDL: 0.8 mmol/ (03/OS/24)
HCO3(st) Ven-POC: 25.8 mmol/L Hct: 44,4 % (13/05/24)
Reactive Hepatitis BSurtace Ab: Peare
(02/05/24)
(03/05/24) Hepatitis B Core Ab: Non (03/05/24)
Hep Bs Ab Num: 525.00 (03/05/24) | HIV Ag/AbCombo: Non
Antigen: Non ReactiveHepatitis CAb: Non Reactive (03/05/24) (03/05/24)
Hepatitis 8 Surface
(03/05/24) (03/05/24) LDL-Cakc: 2.8 mmol/L(03/05/24)
Lactic Acid: 1.2 mmol/L Magnesium: 0..92 mmo/L(13/6/24,
KVen-POC: 3.9 mmo/L (02/05/24)
Lymphocyte Auto #: 2.7 x10^3/uL Lymphocyte Auto %: 35.7% (13/05/24)
13/05/24) MCV: 89.3 fL (13/05/24)
MCH: 30.3 pg (13/05/24) MCHC: 33.9 gm/dL (13/05/24) Monocyte Auto %:9.1 %(13/0Sn4
MetHb Ven-POC: 0.6 % (02/05/24) Monocte Auto #: 0.7 x10^3/uL
(13/05/24) Ven-POC: 133 mmo/L (02/08
MPV: 9.9 fL (13/05/24) MRSA Screening: NEGATIVE (03/05/24) Na
Neutrophil Auto %: 49.3 % (13/05/24) Non HDL: 3.6 mmol/L (03/05/24) O2Hb Ven-POC: 61.0 %(02/05/24)
PDW: 11.3 fL (02/05/24) pH Ven-POC: 7.424 (02/05/24)
PCO2 Ven-POC: 42 mmHg (02/05/24) Prothrombin Time: 16.5 seconds
Platelet: 233 x10^3/uL (13/05/24) PO2 Ven-POC: 32 mmHg (02/05/24)
(13/05/24)
RDW-CV: 14.0 % (13/05/24) RhD: Positive (07/05/24)
RBC: 5.0 x10^6/uL (13/05/24)
RPR Test: Reactive (05/05/24)
RPR Titer: Positive 1:64 (05/05/24) SA Screening: NEGATIVE (03/05/24)
SO2 Ven-POC: 63.2 % (02/05/24) Sodium: 135 mmol/L (13/05/24) TCO2 Ven-POC: 29.1 mmol/L (02/OS/241
tHb Ven-POC: 18.1 gm/dL (02/05/24) Total Protein: 68 gm/L (13/05/24) TPHA Titer: Positive 1:5120 (05/O5/24)
Treponema Pallidum Ab: Reactive Treponema palidum hemagglutination: Triglyceride: 1.8 mmol/L (03/05/24)
(05/05/24) Positive (05/05/24)
Troponin-T HS: 276 ng/L (12/05/24) TSH: 2.91l mIU/L (06/05/24) Urea: 5.9 mmol/L (13/05/24)
Significant Investigations and Procedures:
Echo 02/05
Moderately reduced systolic LV function.
- Biplane LVEF is calculated at 40%.
-Regional wall motion abnormalities (see diagram).
- Grade 1 diastolic dysfunction (normal LA pressure).
- There is a definite large, fixed thrombus on the apical wall measuring 3.2 x1.4 cm.
No significant valvular heart diseases noted
CAG O5/05/24:
Diagnosis: High risk NSTEMI, Apical LV thrombus, EF-40%, Smoker,
Three Vessel Disease
Patient refused Surgical Option, so decided to attempt intervention
Result type: Discharge Summary
Result date: 13 05, 2024 10:47 AST
Result status: Auth (Verified)
Result tite: Discharge HDU B
Performed by: Dr. Fatima Mohamed Sajadi -061512 - Medical Resident on 13 05, 2024 10:47 AST
Verified by: Dr. Fatima Mohamed Sajadi -061512 -Medical Resident on 13 05, 2024 11:33 AST
Encounter info: 0160475403, HH Heart, Inpatient Acute Care, 02/O5/2024
Printed by: Noura Ismail -028275 -Charge Nurse (CF)
Accident &Emergency
Printed on: 13/05/2024 12:09 AST Page 2 of5
D1scharge Summary
"Final Report
ANSAR MEHMOOD GHULAM KAUSAR - HC0304923A
to LAD
Condusions:
multiple wire Attempted
the PCI to LAD With the
support Fine cross and using
leslon was unable to cross and of
ballooning was performed but there was no proximal
Recommendations: PCI to OM/RCA as inpatientflowandacheleved.
out-patient. Refer to CTO
Medical Treatment Team for LAD as
Plavix 75mg once dally for
Aspirin 10OMG For LIfe One Year
Risk Factor Modification
Smoking Cessation.
History of presenting
illness:
This is a 49 years old gentleman, with T2DM
who presented with chest pain
diagnosed this admission:
since 9PM of 01/05/2025, He
Chest pain started after his evening meal. It was retrosternal never had the chest pain. Smoker 60
nearly entire night and got radiated to left arm and left side of pack-year.
relieved when he presented to ED in
Chest pain was associated with neck. Chest pain lasteo o
SOB and HMGH
No palpitations/syncope diaphoresis
Hospital course:
patient was admitted as as case of High risk
showed 3 vessel disease and he was NSTEMI. Fcho showedIVthrombus and he was started on LMWH. his
Surgery Coronary angio was attemptedrecommended for coronary artery angiograpnY
with PC to the LAD which was bypass araft, however the patient strongly rerused
and requested discharge he was started on unsuccessful, the
warfarin clinic in 2days. warfarin for LV thrombus and was dischargedpatient refused another attempt of P
with INR of 1.5 with urgent rererdl to
Medication / Treatment:
Medications (12) Active
Scheduled: (11)
Aspirin 100 mg (enteric
Atorvastatin 40 mg TAB coated) TAB 100 mg 1 tab(s),
40 mg 1 tab(s), Oral, Once a dayOral,
(at
Daily
Bisoprolol 5 mg TAB 5 mg 1 tab(s), Oral, Daily bedtime)
Clopidogrel 75 mg TAB 75 mg 1 tab(s),
Enoxaparin 60 mg/0.6 mL PFS INJ 100Oral, Daily
mg 1 mL, Subcutaneous, q12hr
furosemide 40 mg TAB 40 mg 1 tab(s), Oral, Daily
Insulin Aspart (Novo Rapid) 100 units/mL (10 mL) Vial 2-12
Isosorbide Dinitrate 20 mg (sustained release) TAB unit(s), Subcutaneous, TID
20 mg 1 tab(s), Oral, Daily
Pantoprazole 40 mg TAB 40 mg 1tab(S), Oral, Daily
penicillin G Benzathine 1,200,000 units (900 mg) INJ 2.4
Warfarin Sodium 5 mg TAB+ Warfarin Sodium 1 mg TAB millionunits 2 vial(s), IM, qWeek
6 mg, Oral, Daily
Continuous: (0)
PRN: (1)
Paracetamol 500 mg TAB 1,000 mg 2tab(s), Oral, q6hr
Condition at Discharge:
Result type: Discharge Summary
Result date: 13 05, 2024 10:47 AST
Result status: Auth (Verified)
Result title: Discharge HDU B
Performed by: Dr. Fatima Mohamed Sajjadi - 061512 - Medical Resident on 13 05, 2024 10:47 AST
Verified by: Dr. Fatima Mohamed Sajjadi - 061512 - Medical Resident on 13 05, 2024 11:33 AST
Encounter info: 0160475403, HH Heart, Inpatient Acute Care, 02/05/2024 -
Printed by: Noura Ismail - 028275 - Charge Nurse (CF) -
Accident &Emergency
Printed on: 13/05/2024 12:09 AST
Page 3 of 5
Discharge Summary ANSAR MEHMOooD
Final Report GHULAM KAUBAR
At baseline, ambulating. no chest pain
Discharge disposition:
home
Discharge Medication:
SITagliptin/metFORMIN: 2tab(s),Oral,Daily
SITagliptin/metFORMIN: 2tab(s),Oral,Daily
atorvastatin: 40 mg,Oral,Once a day (at bedtime)
bisoproloL: S ma,Oral, Daily
clopidogrel: 75 mg,Oral,Daily
enoxaparin: 100 mg,1 mL,Subcutaneous,q12hr
glyceryL trinitrate: 1
isosorbide dinitrate: 20spray(s),SL,q5min,PRN
mg,Oral,Daily
(pain-CHEST)
lisinopril: 2.5 mg,Oral, Daily
pantoprazole: 40 mg,Oral, Daily
warfarin: 6 ma,Oral,Daily
warfarin: 5 mg,Oral,Daily
Follow-up
- to be
Instructions:
discharged on enoxaparin 100mg BID + warfarin. INR on
urgent referral to warfarin dinic, to be
seen on 15/05/24.
discharge 1.5. Target INR 2-3.
to continue on warfarin for 3-6
months.
patient was educated to continue on warfarin and
his INR and adjust his
dose.he expressed his
enoxaparin until Wednesday where he will be seen in warfarin clinic to chek
patient was educated on the risk of dischargeunderstanding.
without an intervention multiple times on different
however he insisted on no
intervention and insisted on discharge. occasions ( In his language ),
PGY level:
Noted By:
Dr.Fatima Sajjadi
Internal Medicine, PGY1
Consultant:Dr.Mohammed Khalil, Cardiology Consultant.
Signature Line
Electronically Signed on 13/05/2024 11:33 AST
Dr. Fatima Mohamed Sajjadi - 061512 - Medical
Resident
Dr. Mohamed Khlael Ahmed Mohsen- 021084-
Consultant - Cardiology
Result type: Discharge Summary
Result date: 13 05, 2024 10:47 AST
Result status: Auth (Verified)
Result title: Discharge HDU B
Performed by: Dr. Fatima Mohamed Sajjadi - 061512 - Medical Resident on 13
05, 2024 10:47 AST
Verified by: Dr. Fatima Mohamed Sajjadi - 061512 - Medical
Resident on 13 05, 2024 11:33 AST
Encounter info: 0160475403, HH Heart, Inpatient Acute Care, 02/05/2024 -
Printed by: Noura lIsmail -028275 - Charge Nurse (CF)
Accident &Emergency
Printed on: 13/05/2024 12:09 AST Page 4 of 5
