Simple Cardiology Case Report

1. Introduction

This case report aims to detail the clinical presentation, diagnosis, treatment, and outcomes of a cardiology patient. It is intended for educational purposes to enhance the understanding of similar cases in a clinical setting. The report will discuss a patient suffering from a cardiac condition while highlighting the clinical decisions made throughout the treatment process.

2. Patient Information

A 68-year-old male with a history of hypertension and type 2 diabetes mellitus presented to the emergency department with symptoms of chest pain and shortness of breath.

Demographics

3. Clinical Presentation

The patient reported a sudden onset of chest pain radiating to the left arm, accompanied by dyspnea and sweating. The chest pain duration was approximately 30 minutes before the presentation.

Symptoms

• Chest pain

• Shortness of breath

• Diaphoresis

• Radiating pain in the left arm

4. Diagnosis

Upon admission, the following diagnostic workup was conducted to assess the patient's condition:

Diagnostic Tests

5. Treatment

The patient was diagnosed with an acute myocardial infarction. Immediate medical intervention was initiated as per the standard guidelines for the management of myocardial infarction.

A. Medical Management

• Aspirin 325 mg chewable

• Clopidogrel 300 mg loading dose

• Intravenous heparin infusion

• Statins initiated post-stabilization

B.Procedures

An emergency coronary angiography was conducted, revealing a 90% occlusion of the left anterior descending artery. The patient underwent a successful percutaneous coronary intervention (PCI) with the placement of a drug-eluting stent.

6. Outcomes

The patient's chest pain resolved post-PCI, and he was monitored in the coronary care unit for 48 hours. Subsequent ECGs showed resolution of ST-segment elevation. The patient was discharged on the fifth day with a comprehensive cardiac rehabilitation plan.

Discharge Medications

• Aspirin 81 mg/day

• Clopidogrel 75 mg/day

• Beta-blocker

• ACE inhibitor

• Statin therapy

7. Follow-Up

At a 3-month follow-up, the patient reported adherence to medication and lifestyle changes. Cardiac output had improved, and there were no further episodes of chest pain. The patient continues under regular cardiology follow-up with positive lifestyle modifications.

8. Conclusion

This case underscores the importance of rapid diagnosis and treatment in acute myocardial infarction, highlighting the role of multidisciplinary care and patient education in preventing recurrent cardiac events. Timely intervention and adherence to treatment protocols significantly improved outcomes for the patient.

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