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- A CASE OF CORONARY ARTERY DISEASE –

(99% Blockage of Left Anterior Descending Artery with Left Ventricular  Hypertrophy)

 

Patient named Mr. SS aged 60 years, being diagnosed with CORONARY ARTERY DISEASE with 99% blockage of Left Anterior Descending Artery and initial arteriosclerotic changes in Left Circumflex Artery advised immediate Percutaneous Transluminal Coronary Angioplasty (PTCA) stent knocked the door of Hahnemannian Sciences, may be as the last resort, but still on crucial time with right decision.

 

  • Angiography Reported        :   5th May, 2010
  • D.O.A (at Cardio Life Care) :   20th May, 2010

(After discharged from Coronary Unit,  MediCiti Hospital, Ludhiana)

  • Case C.R.No. (Our Clinic)   :   1796-DB-162

 

ü  CHIEF COMPLAINTS

 

  • Chest Pain (for last 6 months)
  • Breathlessness  (for last 6 months)
  • Cough    (for last 4-5 months)
  • Swelling of Lower Extremities (for last 4-5 months)
  • Palpitation (for last 3 months)
  • Diziness (last 2-3 months, ocassionally)

 

ü  H/O CHIEF COMPLAINTS

 

  • Chest Pain (for last 6 months)

 

- Location         : Substernal region

- Extension       : -------

- Aggaravation  : Slight Exertion

- Amelioration   : -------

 

  • Breathlessness  (for last 6 months)

 

-  Pt. Complained of breathlessness on slight exertion. Even routine work causes exertional dyspnea. (No complaint of Orthopnea or Paroxysmal Nocturnal Dyspnea)

 

  • Cough    (for last 4-5 months)

 

- Non productive cough. Aggravated after breathlessness. Relieved by resting for few minutes.

 

  • Swelling of Lower Extremities (for last 4-5 months)

 

- Swelling of ankles and legs. Pitting edema.

  • Palpitation (for last 3 months)

- Increased Heart Beat with awareness of heart beat. Occurs anytime in the day and goes of its own. Increased mainly with breathlessness.

  • Diziness (last 2-3 months, ocassionally)

 

- Diziness after palpitations and exertion.

 

 

ü  PAST MEDICAL & DRUG HISTORY

 

  • Patient had attack of angina 3 months back with malignant hypertension and was hospitalised.
  • H/O Hypertension for last 3-4 years.
  • H/O Diabetes Mellitus T-2 for last 5 years.
  • No other specific illness in past years.
  • Regularly taking Allopathic Drugs since last 1 year i.e. Gemer forte, Ecosprin, Nitrocontin, Cardace, Embeta XL, Isrdil and some other  drugs (sos).

 

ü  FAMILY HISTORY

 

  • F/H/O Hypertension           -  Mother
  • F/H/O Diabetes Mellitus     -  Mother, Father, Sister, Brother
  • F/H/O Cancer                     -  Sister (Elder Sister died of CA Breast at 40-45 years of age)
  • N/H/O Pulmonary Koch, Asthma in family.

 

 

ü  PERSONAL HISTORY

 

  • Chronic Alcohalic (last 15-20 years). Abstained for last 2 years after Doctor’s advice.
  • Non-Vegetarian Diet, ocassionally.
  • Non Smoker / No other Stimulants or Narcotics consumed ever.

 

ü  GENERALS (including Aetiological Factor at Mental Level)

  • A/F Bad News [6-8 months back, patient had raid on his chemist shop and got entangled in some sort of fake legal matter. His son had to stay in police custody for 3 months after that and this incident changed his life from head to foot. After that he started experiencing these symptoms. He had a very good reputation in the town but after this incident felt all his reputation gone. This was the most worst news of my life ever (Patients Wording)]
  • Loquacity 2+
  • Suspicious 1+
  • Dictatorial 1+
  • Selfish 1+
  • Fear of Heart Disease (marked) 3+
  • Sleep is disturbed because of Anxiety 1+
  • Anxious in Dreams, Dreams about Anxiety.
  • Speech of the patient was hasty. (3+)
  • Thirst : Thirstlessness 1+ (3-4 glasses of water per day in summer days)
  • Hot patient with profuse perspiration on face.
  • Left Sided (Left Side effected, and sleep on left side as well)

 

 

ü  PHYSICAL EXAMINATION

 

  • Pulse    : 68/m
  • B.P       : 150/100 mmHg
  • Temp.   : 98.4`F
  • R/R       : 24/m
  • No sign of Clubbing, cyanosis, icterus, anemia.
  • CVS Exam : S1 S2 Normal, Tachycardia, Low Pitched – S4 sound audible.
  • Lower Extremities pitting oedema.
  • P/A soft, non tender.
  • Chest B/L clear.

 

ü  INTERVENTIONAL INVESTIGATIONS REPORTS

  • CORONARY ANGIOGRAPHY REPORT (dt.: 5TH May, 2010)

 

- Left Main Coronary Artery          : Normal

- Left Anterior Descending Artery : 99% stenosis after D1.

- Left Circumflex Artery                 : Plaque at proximal part.

- Right Coronary Artery                 : Free of any sinificant disease. PDA Normal.

 

Summary               :- CAD (significant single vessel disease)

Recommendation  :- PTCA with stent to LAD

 

ü  NON-INTERVENTIONAL INVESTIGATIONS REPORTS

 

 

  • ECHOCARDIOGRAPHY & COLOR DOPPLER (dt.: 5th May, 2010)

(REPORTED IN DICHARGE SUMMARY OF ANGIOGRAPHY)

 

- Left Ventricular Hypertrophy

- LVEF  :  48%

- ? Mild Apical Septal Hypokinesia

  • ECHOCARDIOGRAPHY & COLOR DOPPLER (dt.: 28TH Jan, 2010)

 

- Left Ventricular Hypertrophy

- LVEF  :  60-65%

- ? Mild Hypokinesia at Basal Septal & Apical LV segment

 

 

 

ü  LABORATORY INVESTIGATIONS REPORTS (5th May, 2010)

 

 

  • HgB   : 14.8 gm%
  • TLC   : 7600 cmm
  • DLC   : N-64, L-30, M-04, E-02
  • Platelets : 2,19,000/cmm
  • Blood Urea : 23n mg/dl
  • Creatinine :  0.79 mg/dl
  • FBS : 127 mg/dl
  • HCV / HbsAg Non Reactive

 

 

DIAGNOSIS

 

  • CAD (svd) 99% stenosis of LAD
  • Mild LV Dysfunction
  • LV Hypertrophy
  • HTn
  • DM T2

 

 

PRESCRIPTION (20TH May, 2010)

  • Lachesis mutus 200c 1 dose STAT (20.5.2010)
  • Lachesis mutus 200c 2 doses (alternate days i.e. 22.5.2010 / 24.5.2010)

 

  • Sumbulus moschatus ‘Q’ 10 drops BD (started from 25.5.2010)
  • PL Liquid 10 drops TDS
  • PL 1 TAB. TDS

 

  • Baryta carbonica 200c 1 dose (intercurrent) Weekly i.e. 27th May; 3rd, 10th, 17th, 25th June

 

  • EMERGENCY KIT (SOS)

 

Arnica montana 10 M           -    1 TAB SOS (CHEST PAIN, To replace Sorbitrate)

Rauwolfia serpentina ‘Q’     -    10 drops SOS (High Blood Pressure)

 

 

ü  MANAGEMENT

Continue to take Blood Pressure and Diabetes Tablet (Allopathic) on regular basis. All other ALLOPATHIC Drugs withdrawn on first day.

  • Proper Diet Chart advised.
  • Exercise daily 30 minutes in fresh air.

 

 

 

ü  FOLLOW UP (28TH June, 2010)

 

N.B. - Patient reported on 28th June, 2010 & told that in last more than 1 month time he had 2 severe attacks of chest pain, but emergency pain sos medicine relieved him (Arnica 10M).

 

Had 4-5 times sudden rise in Blood Pressure and Emergency Medicine was taken with relief in B.P.

 

 

  • Chest Pain relieved 70%, as said by patient, only 2 severe episodes since last month (above mentioned) and 3-4 mild pain attacks which were relieved of their own with rest. No pain on exertion now.

 

  • Breathlessness is almost gone since started the medicine. No breathlessness on exertion. Now patient walks 30 minutes morning and evening daily without any chest discomfort or breathlessness.

 

  • Cough is relieved. Had cough relief from the very first day of medicine.

 

  • Swelling of Lower Extremities is decreased. Edema is non-pitting now.

 

  • Palpitation decreased. Rare palpitation on vigrous exertion only or during anxiety.

 

  • Diziness almost gone.

 

  • NEW SYMPTOMS

 

  • Urination frequency increased.
  • Constipation for last 20 days, ineffectual urge for stool in morning.
  • Perspiration on face increased.
  • Blood Sugar is normal since medicine taken.

 

ü  PHYSICAL EXAMINATION

 

  • Pulse    : 74/m
  • B.P       : 130/90 mmHg
  • Temp.   : 98.4`F
  • R/R       : 20/m
  • No sign of Clubbing, cyanosis, icterus, anemia.

 

  • CVS Exam : S1 S2 Normal, Tachycardia.
  • Lower Extremities non-pitting oedema.
  • P/A soft, non tender.
  • Chest B/L clear.

 

ü  LABORATORY INVESTIGATIONS (DATED 28th June, 2010)

  • HgB   : 12.8 gm%
  • TLC   : 10,800 cmm
  • DLC   : N-79, L-18, M-01, E-02
  • Platelets : 2,17,000/cmm
  • ESR : 10 mm in hr.
  • PBF : Normocytic Normochromic
  • S Uric Acid : 4.7 mg/dl
  • CRP : Negative
  • Cholestrol Total : 134.8 mg/dl
  • S. Triglycerides : 147.1 mg/dl
  • HDL Chol : 55.1 mg/dl
  • LDL Chol : 50.28 mg/dl
  • VLDL : 29.42 mg/dl
  • Blood Urea : 38.7 mg/dl
  • Creatinine :  0. 9 mg/dl
  • S. Sodium : 138.9 meq/l
  • S. Potassium : 4.9 meq/l
  • S. Chloride : 105.9 meq/l
  • LFT : Normal Range
  • RBS : 139.8 mg/dl
  • HCV / HbsAg Non Reactive
  • Urine R/E : Albumin – nil; Sugar - ++

 

ü  PRESCRIPTION (28th June, 2010)

  • Lachesis mutus 200c 1 dose STAT (28.6.2010)

 

  • Sumbulus moschatus ‘Q’ 10 drops TDS (started from 29.6.2010)
  • PL Liquid 10 drops TDS
  • PL 1 TAB. TDS

 

  • Baryta carbonica 200c 1 dose (intercurrent) Weekly i.e. 3rd, 10th, 17th, 25th, 31st  July

 

ADVISED Withdrawl of Blood Pressure and Diabetes Allopathic Tablets in 2 day gap.

 

 

  • ECHOCARDIOGRAPHY & COLOR DOPPLER (dt.: 10th July, 2010)

 

(After 50 days of Treatment)

 

- LEFT VENTRICLE IS NORMAL IN SIZE WITH NORMAL SYSTOLIC FUNCTION

  (LV ENLARGEMENT IN PREVIOUS REPORTS OF ECHOCARDIOGRAPHY)

- LVEF  :  55% (Raised from 48 % in previous report)

- Hypokinesia of Apical Septum and Apex.

 

 

N.B.: PATIENT REFUSING OF ANGIOGRAPHY OR MULTI SLICE CT SCAN OF HEART, AS HE IS ALMOST ASYMPTOMATIC NOW AND HAS NO BOTHERATION TO THE REPORTS OF ANGO/CT SCAN.

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Comment by Abdul Rehman Nadeem on May 19, 2015 at 11:23pm
Excellent symptomatic treatment. Sharing of Labs is of great importance to help understand the case thoroughly. The abbreviation of remedy (PL) liquid not understood. Appreciate if share full name of the drug

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