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buenaventura_48 hour history

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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE \

Name: BUENAVENTURA, DOLORES Age/Sex: 55/F Address: 2558 Singalong Malate, Manila Date of admission: August 9, 2007 Admitting Diagnosis: ACS probably NSTEMI CAD, HCVD, LVH, ST IV-E s/p arrest x 1 Physicians in charge: Drs. Magbiray/ Caole/ Aquino/Aguila/Receno/Dimaandal Intern-in-Charge: Ryan Escandor Clerk-in-Charge: Palay/Rentillo/Roxas

Hospital #: 1719792

48hour history This is a case of a 55 year-old female who came in due to unresponsiveness History of Present Illness Patient is a known hypertensive for about 5 year maintained on Nifedipine. She was apparently well until… Few hrs PTA, patient had sudden onset of loss of consciousness. She was unresponsive with associated circumoral cyanosis. There was no vomiting nor fever noted. Persistence of the condition prompted consult hence the admission Past Medical History No previous operations No allergy, BA, DM Family History (+) HPN, siblings (-) DM, BA Personal and Social History nonsmoker and non alcoholic beverage drinker Review of Systems NA Physical Examination: Comatose, stretcher borne Vital Signs: BP: 150/100-palp 60

HR 114

RR: assisted

HEENT: pink palpebral conjunctivae, anicteric sclerae, no neck vein engorgement, no nasoaural discharge, no cervical lymphadenopathies, no tonsillopharyngeal congestion CHEST AND LUNGS: symmetrical chest expansion, - retraction, no lags, (+) bibasal lung field crackles HEART: adynamic precordium, PMI at 6th ICS LAAL, tachycardic, no murmur, no S3 ABDOMEN: flabby, normoactive bowel sound, soft, non tender EXTREMITIES: grossly normal, full equal pulses, no edema, no cyanosis, (+) pain on active movement of right shoulder Assessment: ACS probably NSTEMI CAD, HCVD, LVH, ST IV-E s/p arrest x 1 PLAN: For admission Patient was admitted to the service of Drs. Aguila, Receno, and Dimaandal. Consent for admission and management was secured. She was hooked to IVF with D5W x KVO to follow. She was placed on NPO temporarily. NGT was inserted and maintained. Laboratory procedures requested were CBC with platelet count, urinalysis, CXR PA, serial ECGq6, 2-D echo with Doppler, FBS, BUN, creatinine, Na+, K+, HDL, LDL, TG, cholesterol, BUA. Medications ordered were ASA 8 mg tab per NGT OD after lunch. Dopamine drip: 250cc D5W + 1 amp dopamine x 18-19 ugtts/min (50 kg at mkd). She was placed on a moderate to high back rest. She was hooked to mechanical ventilator support at TV: 350C; BR: 16 CPM; FiO2 100%; Mode AC. If vent is NA, may do continuous manual ambubagging. Suction secretions regularly. To WOF hypotension, cyanosis with complete bed rest with no bathroom privileges ordered. Upon admission, patient is maintained on NGT. IVF to follow is D5W x KVO with continued dopamine drip at same preparation to run at 18-19 ugtts. O2 support maintained by continuous ambubagging with NA mechanical ventilator. Previously ordered labs were still requested Medications were continued. She is still on a moderate high back rest. VS and NVS monitored q1 with I and O monitoring and CBG every 2 hrs. To WOF progression of neurologic deficit, hypotension, bradycardia and cyanosis. With secretios suctioned regularly.

Patient was referred to service consultant with PWI consideration of hemorrhagic type of stroke, not totally ruling out cardiac pathology. Cranial CT scan was suggested as well as starting Phenytoin. 600 mg TIV at a rate of 50 mg as loading dose then 5 ml (125mg/5mL) every 8 hours per NGT and Dexamethasone 5 mg TIV per NGT. On the 1st hospital day, patient still comatose vital signs were as follows, BP 110/80 CR 113, assisted respiration and temp of 37.3C E2V1M2. NGT was maintained with continued dopamine drip at same preparation to run at 18-19 ugtts/min. O2 support maintained by continuous ambubagging with NA mechanical ventilator. Previously ordered labs were still requested. Medications were continued. Started on Phenytoin. 600 mg TIV at a rate of 50 mg as loading dose then 5 ml (125mg/5mL) every 8 hours per NGT, Citicholine 100 mg / mL 150 mgTIV every 8 hours D5050 for CBG ≤80mg/mL and Dexamethasone 5 mg TIV per NGT, ASA on Hold. She is still on a moderate high back rest. VS and NVS monitored q1 with I and O monitoring and CBG every 6 hrs. To WOF progression of neurologic deficit, hypotension, bradycardia and cyanosis. With secretions suctioned regularly. At 6: 50 pm, pupils 2-3 SRTL (-)Doll’s Eye, Clear breath sounds M3 E1 V1. BP 90/60 CR 110, assisted respiration and temp of 37.7C E2V1M2. NGT was maintained with continued OF feeding. IVF to follow: PNSS 4L x 8. Dopamine drip at same preparation to run at 18-19 ugtts/min. O2 support maintained by continuous ambubagging with NA mechanical ventilator. Previously ordered labs were still requested. Medications were continued. Start Mannitol 100cc to IV q 8 hours. She is still on a moderate high back rest. VS and NVS monitored q1 with I and O monitoring, UO monitoring and CBG every 6 hrs. suction secretion q1 and PRN. To WOF progression of neurologic deficit, hypotension, bradycardia and cyanosis. With secretios suctioned regularly. On the 2nd hospital day, NGT was maintained with continued OF feeding with Sap. IVF to follow: PNSS 1L + 40 megs KCl x 6. to follow up official CT scan result. Previously ordered labs were still requested, in addition, to carry out ABGs, sputum GS/CS, rpt CBC and repeat CXR AP. Medications were continued. Mannitol 100cc to IV q 8 hours continued. She is still on a moderate high back rest. VS and NVS monitored q1 with I and O monitoring, UO monitoring and CBG every 6 hrs. Suction secretion q1 and PRN. Start Cefuroxime 750mg TIV every 8 hours. Azithromycin 2 gram singe dose, Paracetamol 300mg 1-1 and a half amp TIV for temp ≥ 38C. Ventilatory support maintained. Secretions were suctioned regularly. ET tube to be kept patent always! To WOF progression of neurologic deficit, hypotension, bradycardia and cyanosis. At around 9:15 pm, NGT was maintained with continued OF feeding with Sap. IVF to follow: PNSS 1L + 40 megs KCl x 6. to follow up official CT scan result. Previously ordered labs were still requested Medications were continued. Mannitol 100cc to IV q 8 hours continued. She is still on a moderate high back rest. VS and NVS monitored q1 with I and O monitoring, UO monitoring and CBG every 6 hrs. Suction secretion q1 and PRN. Start Cefuroxime 750mg TIV every 8 hours. Azithromycin 2 gram singe dose, Paracetamol 300mg 1-1 and a half amp TIV for temp ≥ 38C. Ventilatory support maintained. Secretions were suctioned regularly. To WOF progression of neurologic deficit, hypotension, bradycardia and cyanosis.


				
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