OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: BAUTISTA , ROBERTO Age/Sex: 65/m Address: Malate Manila Date of admission: July 11,2007 Admitting Diagnosis: CAD,HCVD,LVH, ST-NSR t/c CKD prob 2 to hypertensive nephrosclerosis r/o acute coronary syndrome Final Diagnosis: CKD stage 5 2 to hypertensive nephrosclerosis Residents in charge: Dr.Gonzales/Indon Intern-in-Chage: Maganda Clerk-in-Charge: Navarro/Ponelas/ Reyes
Hospital #: 1707869
This is a case of a 65 year-old male who was admitted due to difficulty of breathing History of Present Illness 1 year PTA, week PTC, patient had productive cough with whitish sputum, no fever, with difficulty of breathing, with orthopnea, no chest pain, no palpitation, no consult done, no meds taken. 2 hrs PTC, there is persistence of the cough with difficulty of breathing while walking thereby prompting consult hence the admission. Past Medical History She was hypertensive for 1 year with unrecalled meds, poor compliance Family History + HPN maternal side - DM,CVD, CA, CKD, asthma Personal and Social History Previous smoker for 1 year stopped >12 years ago Non alcoholic beverage drinker Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Cardiac: (-) PND, + edema x 1 year 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: 110/100-100/80 HR: 124-89 RR: 34-26 Temp: febrile HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (+) distended neckm veins CHEST AND LUNGS: symmetrical chest expansion, + retraction, (+) crakles , (-) wheezes HEART: adynamic precordium,PMI 6th ICS LMCL , no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: + pitting bipedal edema Assessment:
CAD,HCVD,LVH, ST-NSR t/c CKD prob 2 to hypertensive nephrosclerosis r/o acute coronary syndrome
Patient was placed on NPO. IVF was D5W 500 ml x KVO. Diagnostics: 12-L ECG serial, CPK-MB serial, CXR-PA, troponin I quantitative, BUN, creatinine, Na, K, Mg, PT/PTT, CBC with PC, urinalysis, FBS, HDL, LDL, TG, TC, BUA, 2D echo with Doppler, HgA1C. Therapeutics include: 1) Enoxaparin 0.4 ml SL BID, 2) Aspirin 80 mg 1 tab, 4 tab chewed and swallowed, then QID, 3) Clopidogrel 75 mg 1 tab OD, 4) Captopril 25 mg 1 tab, ½ tab TID, 5) Metoprolol 50 mg 1 tab, ½ tab BID, 6) ISMN 60 mg 1 tab, ½ tab BID, 7) ISDN 5 mg 1 tab SL prn for chest pain, 8) Simvastatin 20 mg 1 tab OD, 9) Nalbuphine 10 mg/ml
amp, ½ amp IV prn for severe chest pain, 10) Diazepam 10 mg/2 ml, ½ amp IV OD, 11) Clonidine 75 mg 1 tab SL prn for BP>160/90, 12) Regular insulin 5 units SC prn for CBG > 250 mg/dl On the first hospital day, patient was still on NPO. IVF was maintained. Serial ECG monitoring was continued. Laboratory workups previously requested were carried out and results were followed up. Medications were continued. Cardiac monitor was hooked. Vital signs were monitored every hour. Patient was placed on moderate high back rest. CBG was monitored every 8 hours. Patient was watched out for chest pain, and hypertension. On the second hospital day, patient’s working impression was Unstable angina IB2, CAD, HCVD, LVH, anterolateral wall ischemia, NSR II-B, DM Type 2. Patient was on low salt, low fat diet. IVF was maintained. Medications were continued. Patient was placed on moderate high back rest. CBG was monitored AC/HS. Patient was watched out for chest pain, and difficulty of breathing.