OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: FRANCISCO, MARIO Age/Sex: 46/m Address: Sta.Ana Manila Date of admission: July 18,2007 Admitting Diagnosis: Acute coronary syndrome prob NSTEM K IV CAD t/c Bilateral Cardiomyopathy Cardiomegaly, PVC, E t/c CPC of the liver vs CLD PTB IV Residents in charge: Dr.Magbiray/Gonzales/Filio/Indon Intern-in-Chage: PGI Velasco Clerk-in-Charge: Pineda/ Resurreccion
Hospital #: 1711175
PATIENT DISCHARGE SUMMARY
This is a case of a 46 year-old male who came in due to difficulty of breathing History of Present Illness 1 month PTA, week PTC, patient had easy fatigability of 1 block , orthopnea of 2 pillows, paroxysmal nocturnal dyapnea , bipedal edema, no cough nor colds. Consult was done at IM OPD OMMC, patient was given Furosemide & Spirinolactone providing slight relief of edema. 2 weeks PTA, still with the persistence of the above conditions, ff up check up was done. Patient medicated with Furosemide & Spirinolactone which the patient took , providing no relief of bilateral edema which progressed up to the leg. 1 day PTA, still with persistence of above conditions, edema progressed up to the abdomen, associated with chest pain, severity of 7/10, radiating to the back. Persistence prompted consult hence the admission. Family History 1993- CAD, Cardiomegaly, no meds no consult + HPN- HBP= 140/90 UBP= 130/80 Personal and Social History >20 years shabu and marijuana user Non alcoholic beverage drinker 10 pack years smoking hx Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Gastrointestinal: (-) abdominal pain, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (+) polyuria, (+) polyphagia, (+) polydipsia Muscular: - general body weakness Physical Examination: conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 120/80 HR: 74 RR: 24 Temp: 37.2 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (+) distended neckm veins CHEST AND LUNGS: symmetrical chest expansion, - retraction, (+) diffuse crakles , (-) wheezes HEART: adynamic precordium,PMI 6th ICS AAL , NRRR, no murmur ABDOMEN: globular, normoactive bowel sound, soft, non-tender EXTREMITIES: + grade4 bipedal edema, full equal pulses Assessment: Acute coronary syndrome prob NSTEM K IV CAD t/c Bilateral Cardiomyopathy Cardiomegaly, PVC, E t/c CPC of the liver vs CLD PTB IV PLAN: Patient was admitted to the service of Drs. Magbiray, Gonzales, Filio, and Estrada. Consent for admission was secured. Patient was put on NPO while IVF given was D5W x KVO. Diagnostic procedure requested were: RBS, ECG, CXR PA, Na, K, CL, CBC with PC, UA, HgbAic, FBS, Bun, Crea, Choleterol, TG, HDL, LDL, APTT, PT, and 2 D echo. Medications prescribed were: Enoxaparin 0.4 mL SQ BID, ASA 80mg/tab OD, Nalbuphine 10mg/amp TIV for severe chest pain with BP precaution, Diazepam 10mg/amp ½ amp TIV at HS, Spirinolactone 50 mg BID PO, Furosemide 40mg TIV q12, Captopril 25 mg 1 tab TID PO, ISMN 30mg BID PO, ISDN 5 mg SL prn for chest pain. O2 support via nasal canula.
On the 1st hospital day,OFI was decreased , low salt low fat diet, IVF TF: D5W x KVO, still for 2d echo c Doppler, Previously requested labs were followed up. O2 support via nasal canula at 3-4 ppm was maintained. VS q1, CR and RR in full minute, Moderate to high back rest. On the second day of admission, OFI was decreased to <1L, low salt low fat diet. Continue Furosemide drip. O2 support via nasal canula at 3-4 ppm was maintained. VS q1, CR and RR in full minute, Moderate to high back rest. On the third day of admission, the patient was referred to Cardiology service and suggests carry out of 2-D echo without fail. Patient was for determination of Creatinine, K, total cholesterol. Patient was also for Prothrombin time determination. Meds: Furosemide drip: D5W 250 cc + 250mg/amp 25 mgtts/min, Digoxin 0.25 mg TIV every 6 hours in 3 doses the n OD, ISMN 60 mg tab was shifted to ISDN 10 mg tab q6 and Heparin 1000 SC BID. D/C of metoprolol and furosemide tablet was done. OFI was limited to 1L/ day. In moderate high back rest. Strict input and output monitoring. Vital signs monitored every 1 hour, CR and RR in full minute. On the 4th hospital day, low fat and low salt diet was advised. OFI was limited to <1L/day. Patient was still for 2D-echo. Vital sign monitoring every 1 hour. On the 5th day of admission, low fat and low salt diet was advised. OFI was limited to <1L/day. Vital sign monitoring every 1 hour. Meds and Furosemide drip was continued. On the 6th day of admission, low fat and low salt diet was advised. OFI was limited to <1L/day. Vital sign monitoring every 1 hour. Meds and Furosemide drip was continued. On the 7th day, the patient was still for angiogram. May shift to long acting nitrates. For Creatinine determination. Furosemide can now be shifted to oral form. ISDN can be shifted to ISMN 60 mg tab ½ tab BID. Vital sign monitoring every 1 hour RR in full minute. On the 8th day of admission, patient may go home with the following home meds: 1. ASA 80/tab mg OD PO, 2. Captopril 25 mg/tab 1 tab TID PO, 3. Simvastatin 20 mg/ tab OD PO, 4. ISMN 30 mg/tab BIDPO, 5. Furosemide 20 mg/tab BID PO, 6. Digoxin 0.25 /tab OD PO. Patient is still for Creatinine determination and for angiography on OPD basis. Patient was advised to follow-up at IM-OPD 1 PM. She was well advised.
SUMMARY OF LABORATORY STUDIES
Clinical Microscopy (Urinalysis) (18 July 2007) Physical: Microscopic: color: Transparency: Epithelial cells Mucus thread: Amorphous urates: Pus cells: Erythrocytes: Albumin: Sugar: Sp. gravity pH Dark Yellow clear occasional occasional few 1-2/hpf 3-5/hpf +1 negative 1.030 6
Hematology Report WBC RBC HGB HCT MCV MCH MCHC PLATELET NEUTROPHILS LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS 18 July 07 8.1 4.8 15.3 43.6 91.5 32 35 180 65.1 27.8 6.6 0.5 0 19 July 07 6.4 4.1 13 37.9 91.9 31.5 34 173 65.7 28.9 3.6 1.4 0.4
2D Echo (July 22, 2007) Echocardiographic findings: The left ventricle is dilated with hypokinesia of all segments with severe involvement of inferior and lateral walls and mild to moderate involvement of anterior free wall, and moderately depressed overall systolic function. The left atrium, right ventricle, and right atrium are dilated. There is flattening of the IV septum during diastole and systole consistent with RV volume and pressure overload. The aortic root and main pulmonary artery are normal in size. The mitral, tricuspid, and pulmonic valves are structurally normal. The right coronary cusp of the aortic valve is thickened with no restriction of motion. There is no thrombus nor vegetation. No pericardial abnormality noted. Doppler study: Abnormal mosaic color flow across the cardiac valves. The pulmonary artery pressure by TR jet is 57 mmHg while by acceleration time is 59 mmHg consistent with moderate pulmonary HPN. Conclusion: Multichambered dilatation with multisegmental wall motion abnormality and moderately depressed systolic function. Signs of RV volume and pressure overload. Aortic sclerosis and aortic insufficiency, +2 Mitral regurgitation, mild Tricuspid regurgitation severe Pulmonic regurgitation Moderate pulmonary hypertension