ignacio leonida updated verify 4-4-08 by dredwardmark

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Ignacio, Leonida Age/Sex: 63/F Address: 1840 G. Tuazon St. Sampaloc, Manila Date of admission: April 1, 2008 Admitting Diagnosis: CHF IV IHD, LVH, ST, E DM Type II Residents in charge: Dr. Esmero/Estrada/Cortes Clerk-in-Charge: Kalalo/Lingao

Hospital #: 1817980

Clinical Abstract This is a case of a 63/F who came in due to dyspnea. History of Present Illness Two months PTA, patient noted of having bipedal edema and easy fatigability. There is no Orthopnea, PND or chest pain. No consult or medications were taken. 1 month PTA, edema progressed up to the back of the legs. Previous symptoms were still present. Patient consulted at the Ospital ng Sampaloc. No diagnosis was given and prescribed medications were unrecalled. One week PTA, edema progressed to both thighs. Three-pillow orthopnea and PND was also present together with the patient’s previous symptoms. Patient again consulted at the Ospital ng Sampaloc. Prescribed medications were unrecalled Four hours PTA, the above symptoms persisted. This prompted consult at the OMMC-ER. Past Medical History (+) DM Type 2, diagnosed in 1995, previously on Gliclazide with good compliance; at present, medications are unrecalled (+) cataract No PTB, Hypertension, DM, or Asthma Family History (+) Asthma – sibling Personal and Social History Non smoker, non alcoholic beverage drinker Review of Systems General: (-) weight loss, (-) anorexia HEENT: (-) dizziness, (-) tinnitus, (-) dysphagia Respiratory: (+) 1 week cough, (-) colds Cardiac: (-) chest pain, (-) PND, (-) no orthopnea, (-) palpitations GIT: no abdominal pain, no vomiting, no melena, no change in bowel movement Genitourinary: (-) dysuria, (-) hematuria, (-) oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Hema: (+) easy bruisability Musculoskeletal: (+) myalgia, (-) arthralgia Neurologic: (-) seizure, (-) loss of consciousness Physical Examination: Conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 180/130 HR: 96 RR: 38 Temp: 36.20C SKIN: (+) diaphoresis, no pallor, no cyanosis HEENT: pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no mass, no lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, no lagging, (+) diffuse crackles with occasional rhonchi HEART: adynamic precordium, tachycardia, PMI 5th LICS MCL, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: grossly normal, no cyanosis Assessment: CHF IV IHD, LVH, ST, E DM Type II

Plan: I and O monitoring; NPO; IVF: PNSS 1L 40mEq KCl x 10 hr Labs: ECG, CXR, Blood CS 2 sites, Sputum GS/CS/AFB, CBC, UA, Na, K, Cl, Bun, Crea Medications: 1. PZA + INH + Ethambutol + Rifampicin (Myrin P) 2 tabs OD 2. Vitamin B complex 1 tab OD 3. Tazobactam + Piperacillin 2.25g IV q8 ANST 4. Clarithromycin 500mg BID/NGT

5. Salbutamol neb q4 hr Hook to O2 inhalation at 10 lpm via facial mask Moderate high back rest VS q1 Emergency kit at bedside for possible intubation

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Ignacio, Leonida Age/Sex: 63/F Address: 1840 G. Tuazon St. Sampaloc, Manila Date of admission: April 1, 2008 Admitting Diagnosis: CHF IV IHD, LVH, ST, E DM Type II Residents in charge: Dr. Esmero/Estrada/Cortes Clerk-in-Charge: Kalalo/Lingao

Hospital #: 1817980

24 HOUR HISTORY This is a case of a 63/F who came in due to dyspnea. History of Present Illness Two months PTA, patient noted of having bipedal edema and easy fatigability. There is no Orthopnea, PND or chest pain. No consult or medications were taken. 1 month PTA, edema progressed up to the back of the legs. Previous symptoms were still present. Patient consulted at the Ospital ng Sampaloc. No diagnosis was given and prescribed medications were unrecalled. One week PTA, edema progressed to both thighs. Three-pillow orthopnea and PND was also present together with the patient’s previous symptoms. Patient again consulted at the Ospital ng Sampaloc. Prescribed medications were unrecalled Four hours PTA, the above symptoms persisted. This prompted consult at the OMMC-ER. Past Medical History (+) DM Type 2, diagnosed in 1995, previously on Gliclazide with good compliance; at present, medications are unrecalled (+) cataract No PTB, Hypertension, DM, or Asthma Family History (+) Asthma – sibling Personal and Social History Non smoker, non alcoholic beverage drinker Review of Systems General: (-) weight loss, (-) anorexia HEENT: (-) dizziness, (-) tinnitus, (-) dysphagia Respiratory: (+) 1 week cough, (-) colds Cardiac: (-) chest pain, (-) PND, (-) no orthopnea, (-) palpitations GIT: no abdominal pain, no vomiting, no melena, no change in bowel movement Genitourinary: (-) dysuria, (-) hematuria, (-) oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Hema: (+) easy bruisability Musculoskeletal: (+) myalgia, (-) arthralgia Neurologic: (-) seizure, (-) loss of consciousness Physical Examination: Conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 180/130 HR: 96 RR: 38 Temp: 36.20C SKIN: (+) diaphoresis, no pallor, no cyanosis HEENT: pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no mass, no lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, no lagging, (+) diffuse crackles with occasional rhonchi HEART: adynamic precordium, tachycardia, PMI 5th LICS MCL, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: grossly normal, no cyanosis Assessment: CHF IV IHD, LVH, ST, E DM Type II

Plan: I and O monitoring; NPO; IVF: PNSS 1L 40mEq KCl x 10 hr Labs: ECG, CXR, Blood CS 2 sites, Sputum GS/CS/AFB, CBC, UA, Na, K, Cl, Bun, Crea Medications: 1. PZA + INH + Ethambutol + Rifampicin (Myrin P) 2 tabs OD

2. Vitamin B complex 1 tab OD 3. Tazobactam + Piperacillin 2.25g IV q8 ANST 4. Clarithromycin 500mg BID/NGT 5. Salbutamol neb q4 hr Hook to O2 inhalation at 10 lpm via facial mask Moderate high back rest VS q1 Emergency kit at bedside for possible intubation Course in the Wards: On the first hospital day, patient was maintained on heplock. Previous medications were continued. Patient was placed on moderate high back rest. VS were monitored q1. Patient was watched out for decrease in BP, chest pain and DOB.

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Ignacio, Leonida Age/Sex: 63/F Address: 1840 G. Tuazon St. Sampaloc, Manila Date of admission: April 1, 2008 Admitting Diagnosis: CHF IV IHD, LVH, ST, E DM Type II Residents in charge: Dr. Esmero/Estrada/Cortes Clerk-in-Charge: Kalalo/Lingao

Hospital #: 1817980

48 HOUR HISTORY This is a case of a 63/F who came in due to dyspnea. History of Present Illness Two months PTA, patient noted of having bipedal edema and easy fatigability. There is no Orthopnea, PND or chest pain. No consult or medications were taken. 1 month PTA, edema progressed up to the back of the legs. Previous symptoms were still present. Patient consulted at the Ospital ng Sampaloc. No diagnosis was given and prescribed medications were unrecalled. One week PTA, edema progressed to both thighs. Three-pillow orthopnea and PND was also present together with the patient’s previous symptoms. Patient again consulted at the Ospital ng Sampaloc. Prescribed medications were unrecalled Four hours PTA, the above symptoms persisted. This prompted consult at the OMMC-ER. Past Medical History (+) DM Type 2, diagnosed in 1995, previously on Gliclazide with good compliance; at present, medications are unrecalled (+) cataract No PTB, Hypertension, DM, or Asthma Family History (+) Asthma – sibling Personal and Social History Non smoker, non alcoholic beverage drinker Review of Systems General: (-) weight loss, (-) anorexia HEENT: (-) dizziness, (-) tinnitus, (-) dysphagia Respiratory: (+) 1 week cough, (-) colds Cardiac: (-) chest pain, (-) PND, (-) no orthopnea, (-) palpitations GIT: no abdominal pain, no vomiting, no melena, no change in bowel movement Genitourinary: (-) dysuria, (-) hematuria, (-) oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Hema: (+) easy bruisability Musculoskeletal: (+) myalgia, (-) arthralgia Neurologic: (-) seizure, (-) loss of consciousness Physical Examination: Conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 180/130 HR: 96 RR: 38 Temp: 36.20C SKIN: (+) diaphoresis, no pallor, no cyanosis HEENT: pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no mass, no lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, no lagging, (+) diffuse crackles with occasional rhonchi HEART: adynamic precordium, tachycardia, PMI 5th LICS MCL, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: grossly normal, no cyanosis Assessment: CHF IV IHD, LVH, ST, E DM Type II

Plan: I and O monitoring; NPO; IVF: PNSS 1L 40mEq KCl x 10 hr Labs: ECG, CXR, Blood CS 2 sites, Sputum GS/CS/AFB, CBC, UA, Na, K, Cl, Bun, Crea Medications: 1. PZA + INH + Ethambutol + Rifampicin (Myrin P) 2 tabs OD 2. Vitamin B complex 1 tab OD

3. Tazobactam + Piperacillin 2.25g IV q8 ANST 4. Clarithromycin 500mg BID/NGT 5. Salbutamol neb q4 hr Hook to O2 inhalation at 10 lpm via facial mask Moderate high back rest VS q1 Emergency kit at bedside for possible intubation Course in the Wards: On the first hospital day, patient was maintained on heplock. Previous medications were continued. Patient was placed on moderate high back rest. VS were monitored q1. Patient was watched out for decrease in BP, chest pain and DOB. On the second hospital day, patient was maintained on heplock. Previous medications were continued. Patient was placed on moderate high back rest. VS were monitored q1.Patient was started on Metoprolol 50mg/tab, ¼ tab BID. CBG was monitored every 8 hours. Patient was scheduled for chest x-ray.12 L ECG will be done OD. KUB ultrasound showed Renal Parenchymal Disease with bilateral Pelvicocalyctesia; Normal Urinary Bladder.

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Ignacio, Leonida Age/Sex: 63/F Address: 1840 G. Tuazon St. Sampaloc, Manila Date of admission: April 1, 2008 Admitting Diagnosis: CHF IV IHD, LVH, ST, E DM Type II Residents in charge: Dr. Esmero/Estrada/Cortes Clerk-in-Charge: Kalalo/Lingao

Hospital #: 1817980

Patient Discharge Summary This is a case of a 63/F who came in due to dyspnea. History of Present Illness Two months PTA, patient noted of having bipedal edema and easy fatigability. There is no Orthopnea, PND or chest pain. No consult or medications were taken. 1 month PTA, edema progressed up to the back of the legs. Previous symptoms were still present. Patient consulted at the Ospital ng Sampaloc. No diagnosis was given and prescribed medications were unrecalled. One week PTA, edema progressed to both thighs. Three-pillow orthopnea and PND was also present together with the patient’s previous symptoms. Patient again consulted at the Ospital ng Sampaloc. Prescribed medications were unrecalled Four hours PTA, the above symptoms persisted. This prompted consult at the OMMC-ER. Past Medical History (+) DM Type 2, diagnosed in 1995, previously on Gliclazide with good compliance; at present, medications are unrecalled (+) cataract No PTB, Hypertension, DM, or Asthma Family History (+) Asthma – sibling Personal and Social History Non smoker, non alcoholic beverage drinker Review of Systems General: (-) weight loss, (-) anorexia HEENT: (-) dizziness, (-) tinnitus, (-) dysphagia Respiratory: (+) 1 week cough, (-) colds Cardiac: (-) chest pain, (-) PND, (-) no orthopnea, (-) palpitations GIT: no abdominal pain, no vomiting, no melena, no change in bowel movement Genitourinary: (-) dysuria, (-) hematuria, (-) oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Hema: (+) easy bruisability Musculoskeletal: (+) myalgia, (-) arthralgia Neurologic: (-) seizure, (-) loss of consciousness Physical Examination: Conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 180/130 HR: 96 RR: 38 Temp: 36.20C SKIN: (+) diaphoresis, no pallor, no cyanosis HEENT: pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no mass, no lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, no lagging, (+) diffuse crackles with occasional rhonchi HEART: adynamic precordium, tachycardia, PMI 5th LICS MCL, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: grossly normal, no cyanosis Assessment: CHF IV IHD, LVH, ST, E DM Type II

Plan: I and O monitoring; NPO; IVF: PNSS 1L 40mEq KCl x 10 hr Labs: ECG, CXR, Blood CS 2 sites, Sputum GS/CS/AFB, CBC, UA, Na, K, Cl, Bun, Crea Medications: 1. PZA + INH + Ethambutol + Rifampicin (Myrin P) 2 tabs OD 2. Vitamin B complex 1 tab OD

3. Tazobactam + Piperacillin 2.25g IV q8 ANST 4. Clarithromycin 500mg BID/NGT 5. Salbutamol neb q4 hr Hook to O2 inhalation at 10 lpm via facial mask Moderate high back rest VS q1 Emergency kit at bedside for possible intubation Course in the Wards: 2 On the first hospital day, patient was maintained on heplock. Previous medications were continued. Patient was placed on moderate high back rest. VS were monitored q1. Patient was watched out for decrease in BP, chest pain and DOB. 3 On the second hospital day, patient was maintained on heplock. Previous medications were continued. Patient was placed on moderate high back rest. VS were monitored q1.Patient was started on Metoprolol 50mg/tab, ¼ tab BID. CBG was monitored every 8 hours. Patient was scheduled for chest x-ray.12 L ECG will be done OD. KUB ultrasound showed Renal Parenchymal Disease with bilateral Pelvicocalyctesia; Normal Urinary Bladder. 4 On the third hospital day, heplock was maintained and patient was placed on NPO temporarily except meds then shifted to soft diet after 10 hours. Labs requested were: Troponin I quanti, ABG, Ca and Mg, 12L ECG OD. IVF was PNSS + 60 mEqs KCl x 24h. KCl 2 tabs BID was started. At around 10PM, patient was noted to be unresponsive. D50/50 1 vial was given TIV and diazepam ½ amp TIV. 12L ECG was again ordered. O2 was given at 2-4 lpm via nasal cannula. 5 On the fourth hospital day, soft diet was maintained. Previous order of PNSS+KCl was deferred. Patient was instead hooked on PNSS 80cc + 40mEqs KCl x 4h. CBG monitoring was ordered q6. Patient is also for transfer to425/427 once a vacancy is available. 6 On the 5th hospital day, patient was still for transfer to 427. Patient was given low salt low fat diet. Patient was for repeat serum K, urinalysis and 2D echo with Doppler. Medicines being given were Aspirin 80mg OD PO after lunch, Captopril 25mg TID PO, Metoprolol 50mg ½ tab BID PO, Furosemide 40mg IV q12, Spironolactone 50mg BID PO, Intermediate Insulin 12 u SC in AM, 6 u SC in PM, regular insulin 5 u SC PRN for CBG> 200u/dl and KCl tab TID PO. Patient was maintained on moderate high back rest. Vital signs were monitored every 2 hours. 7 On the 6th hospital day, patient’s diet was

CXR (3-31-08): PTB both lungs with volume loss on the R; atherosclerotic aorta; pleurodiaphragmatic adhesion bilateral (4-03-08): PTB activity undetermined. Lung abscess upper lobe. Koch’s pneumonia not ruled out for follow up. Atheromatous aorta. CBG (4-1-08) : 160 mg/dl HEMATOLOGY: DATE WBC RBC HgB Hct MCV MCH MCHC RDW-CV Platelets Neutrophils Lymphocytes Monocytes Eosinophils Basophils Pro/Mye/Jv Stabs Blasts ESR mm/hr Ret NRBC Malaria LE BT CT CRT RBC Morph

NORMAL 4-11 x 109 /L 4-6 x 1012/L 120-180 g/L 0.37 – 0.54 % 80-100 fL 27-31 pg 320-360 g/L 11-15% 15-45 x 1012 /L 0.5 – 0.7 0.2 -0.44 0.02-0.09 0.02-0.04 0 – 0.02 0.00 0.02 – 0.04 0.00 0-10 / 20 0.005- 0.015

3-3108 8.8 3.66 11.2 32.0 87.7 30.7 35.0 17.1 572 84.3 7.8 5.5 0.5 1.9

1 – 3 min 6 – 15 min 50% / hr

URINALYSIS DATE Color Transparency Sp. Gravity pH Sugar Albumin RBC WBC Cast Crystals Epithelial cells Bacteria Mucous Thr Pus cells Amorphous urates

NORMAL

3-31-08
LIGHT YELLOW SLIGHTLY TURBID

1.016 – 1.022 4.6 – 6.5 (-) (-) 0-2 /hpf 0-5 / hpf

1.015 6.5
NEGATIVE TRACE

24-26/HPF (TRAUMATIC TAP)
HYALINE 12/HPF CALCIUM OXALATE: OCCASIONAL FEW FEW FEW

Acidic/alkali Few (-) Few

1-3/HPF
FEW

BLOOD CHEMISTRY DATE Glucose BUN mmol/L Crea mmol/l BUN:Crea Total Protein Albumin Globulin Ca mmol/L Mg mmol/L Na mmol/L K mmol/L Cl mmol/L Phosphorus Cholesterol mmol/l HDL mmol/L LDL mmol/L Triglycerides TB umol/L DB umol/L IB umol/L ALT/SGPT U/L AST/SGOT U/L Urate mmol/L Amylase CPK total CPK –MM CPK – MB Troponin T/I BUA ųmol/L Alk Phos U/L

NORMAL 3.9-6.4 MMOL/L 21.7-8.3 MMOL/L 59-104 (MALE) 45-84 (FEMALE) 66-87 g/L 34-48 g/L 20-38 g/L 2.2 – 2.6 0.74 – 1.0 134-145 3.4-5 93-108 0.81 – 1.58 3.8-5.1 0.91-1.56 1.32-2.52 0.4-2.25 0.00 – 17.1 0-5.1 3.42 – 13.7 0-41 male 0-35 female 0-38 male 0-32 female 0.13 – 0.44 1 – 63 U/L 21 – 232 U/L 8 – 97 U/L

APR 2008 6.2 64.62

APR 4 2008

137 2.6 93 5.76 0.87 4.5 0.88

0.11-0.43 mmol/L 35-129

0.63


								
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