Patient Diagnosis - Cardiovascular case History of patient Name John Gibbons Age 67 Gender male Weight 95 kg BMI: 31 kg/m2 Occupation Retired accountant General health Generally good, sedentary lifestyle, lives with wife Existing chronic conditions Type 2 diabetes mellitus Hypercholesterolemia Ex-smoker (quit 5 years ago) Gout Medication Diabetes treatment (Metformin and gliclazide) Hypertension treatment (valsartan/hydrochlorothiazide) Hypercholesterolemia treatment (atorvastatin) Gout treatment (allopurinol) Thyroid treatment (thyroxine) Hypertension COPD Hypothyroidism Non-alcoholic fatty liver disease Presentation Mr Gibbons has presented to the emergency department with a sudden onset of shortness of breath, orthopnoea (shortness of breath when lying flat), paroxysmal nocturnal dyspnoea (attacks of breathlessness at night) and increased ankle swelling. He has had a productive cough for the last seven days. Six weeks ago he made a visit to his sister in Bangkok. While being there, he suffered from an episode of travellers' diarrhoea which resolved after 3 days. Over the last year, he has had a few episodes of chest pain that resolved by itself and he never sought medical attention for these. Tests undertaken Physical examination: -increased respiratory rate -temperature 37.9 C -BP 1tf9/104 mmHg -elevated jugular venous pressure -crepitations on auscultation of the lungs
Electrocardiogram: ECG showing anterior pathological Q-waves and T-wave 1 mr ¥3 #VR V4 V5 aVE V6 ECG courtesy of Dr. De Jong and ECGpedia.org ECG(OPEDIA.ORG Chest X-ray:
ERECT RA MOBILE Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 3011 Name Dr Student number Diagnosis and Patient Plan Record /20 Diagnosis (2): Data relevant to/ that assisted in making the diagnosis (5) Data not relevant to the decision (5) Proposed treatment (2) Expected effect of the treatment (2) Additional (potentially non- standard) testing that might confirm or change your diagnosis; justify why (4)