OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: LEDDA, BENEDICTO Age/Sex: 78/m Address: 405 Leandro Ibarra St., Tondo, Manila Date of admission: July 15,2007 Admitting Diagnosis: ACS prob NSTEMI KI CAD, HCVD,LVH,LAHB, anterolateral wall ischemia, NSR, E BPH Residents in charge: Drs. Magbiray/Caole/Aguila/Receno/Dimaandal Clerk-in-Charge: Ocampo/Reloj/Rosarito
Hospital #: 762265
48 HOUR HISTORY This is a case of a 78 male from Tondo who came in due to chest pain.
History of Present Illness Patient is a diagnosed case of CAD, HCVD, LVH, LAHB, NSR, II-B S/P MI (1997, Phil Heart Center) maintained on Metoprolol, Telmisartan, ASA, ISDN, Micorandil, Simvastatin with good compliance. Patient was apparently well until... 7 hours PTA, after urinating, patient noted (+) chest pain,sudden onset, substernal, crushing, nonradiating, 8/10 in severity and not relieved by rest. There is no abdominal pain, no fever, no DOB, no dizziness. Patient self -medicated with ISDN SL affording temporary relief. No consult was done. 4 hours PTA, there is persistence of above condition but with noted decrease in severity. Patient took ISDN affording slight relief. Still no consult was done. Few minutes PTA, there is persistence of above condition with note of 7/10 in severity prompted consult at OMMC-FM. At the ER (FM), there is chest painas previously described. Patient was given ISDN three doses every 15 minutes apart, affording temporary relief, hence, referral. At the ER (IM), patient was noted to have chest pain, substernal, heavy in character, 3/10 in severity, non radiating, tolera ble. ECG revealed LAHB. Trop I revealed (+) result, hence admission.
Past Medical History No previous operation No DM No BA (+) BPH - Alfusozin Family History (+) HTN - siblings Personal and Social History Nonsmoker Non alcoholic beverage drinker 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 Endo: (-) polyuria, (-) polyphagia, (-) polydipsia Rheuma: (-) joint pains Hema: (-) no easy bruisability
Physical Examination: conscious, coherent, NICRD Vital Signs: BP: 160/100-170/80 HR: 78 RR: 19 Temp: 36.6 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds, no crackles HEART: adynamic precordium, PMI 6th ICS LMCL, NRRR, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: grossly normal, full and equal pulses, no edema
Assessment: ACS prob NSTEMI KI CAD, HCVD,LVH,LAHB, anterolateral wall ischemia, NSR, E BPH
PLAN: Patient was admitted until the service of Drs. Magbiray/Caole/Aguila/Receno/Dimaandal. Management plans for the patient were: TPR q shift, I and O monitory, NPO temporarily except meds, IVF TF – D5W x KVO 500cc. Diagnostics requested for the patient are: 2D echo with Doppler, T-op quantitative, Na, K, Cl, BUA, UA, FBS, RBS, 12-L ECG q 6, BUN, CREA, Chole, TG, HDL, LDL, CBC with PC, CXR -PA. Therapeutics: Enoxaparine 0.4 mg/ml 5Q BID; Metoprolol 50 mg tab BID PO; Captopril 25 mg tab TID PO; ASA 80 mg tab OD PO after lunch; Simvastatin 20 mg tab ½ tab OD PO; Omeprazole 40 mg tiv OD; Diazepam ½ amp tiv at bedtime; ISMN 30 mg tab BID; ISDN 5 mg t ab SL prn for chest pain; Nalbuphine 1 amp tiv prn for severe chest pain; Terazosin 2 mg tab OD PO; Captopril 25 mg SL prn for BP≥160/1 00. IIC/CIC to do complete data base; for referral to SVC consultant; mod high back rest; hook to cardiac monitor; complete bed rest with no bathroom privilege. WOF chest pain, DOB, abdominal pain. VSq1, CR and RR full minute, UO monitoring, refer. In the ICU, the patient is ordered to be in NPO temporarily; IVF: maintain D5W at KVO; carry out previously requested labs to include PSA; for UTZ of KUB and prostate; carry admitting order; continue meds; maintain on O2 support via nasal canula; hook to cardiac monitor if available; complete bed rest without BP. WOF recurrence of chest pain, DOB. VSq1, CR and RR full minute, UO monitor; Close watch, ref. COURSE IN THE WARDS: st 1 hospital day, patient had generalized liquid with SAP. Patient is maintained on IVF. Patient was requested for 2D-echo with Doppler. Labs were carried out: Trop I quantitative, BUN, Crea, Na, K, Chole, TG, HDL, LDL, FBS. Patient was also scheduled for UTZ of KUB. Diazepam was shifted on prn basis. ISMN was hold temporarily. ISDN was shifted to 5mg/tab TID; Simvastatin was increased to 40 mg/tab OD. Patient was still on VSq1 monitoring. WOF dyspnea. Ref. 2nd hospital day, Isoket drip was started, D5W 90 ml + 10 mg Isoket in soluset drip of 15 ugtts/min. ISDN was hold temporarily. Ref. IV is maintained. Patient went out for 2D echo with Doppler. Patient is still for KUB and prostate UTZ. Omeprazole is discontinued. Maintain on moderate to high back rest. VSq1. WOF chest pain, dyspnea. Ref.