OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE Name: Estalane, Francisco Age/Sex: 69/M Address: 2058 Santiago St. Valenzuela City Date of Admission: April 13, 2008 Admitting Diagnosis: NSTEMI CAD, Anteroseptal wall Ischemia NSR-E HCVD, LVH UTI Intestinal Parasitism (Hookworm) Final Diagnosis: Residents in charge: Drs. Receno/Roxas/Indon/Cruz Clerks in charge: Kalalo/Lingao Hospital No: 1823307 Clinical Abstract This is a case of a 69-year old male from Valenzuela who came in due to abdominal pain. History of Present Illness Two days PTA, patient complained of abdominal pain, vague, periumbilical and non radiating. Patient also experienced generalized body weakness, easy fatigability, dyspnea and drowsiness. Patient consulted a private clinic where he was given a diagnosis of UTI and intestinal parasitism. Medications were unrecalled. Few hours PTA, abdominal pain increased in severity. This prompted consult at the OMMC-ER where he was subsequently admitted. Past Medical History No HTN, DM, Asthma No allergies No operation Family History Denies any heredofamilial disease Personal Social History Non-smoker Alcoholic beverage drinker consuming 2 bottles of Red Horse/day in 40 years Review of Systems Gen: no weight loss, no loss of appetite HEENT: no blurring of vision, no tinnitus, no dysphagia Respiratory: no cough, no colds,no hemoptysis Cardiac: no easy fatigability, no orthopnea, no PND, no chest pain GIT: no abdominal pain, no change in bowel movement GUT: (+)dysuria, no oliguria, no hematuria Endo: no polyuria, no polyphagia, no polydipsia Hema: no easy bruisability MSS: no myalgia, no arthralgia Physical Examination Gen: conscious, coherent not in cardiorespiratory distress BP: 110/70 CR: 88 bpm RR:21 cpm T: 370C HEENT: anicteric sclerae, pink palpebral conjunctivae, no alar flaring, no mass, no neck vein engorgement C/L: symmetrical chest expansion, no lagging, no retractions, clear breath sounds Heart: adynamic precordium, normal rate, regular rhythm, PMI at 6th ICS LAAL, no murmur Abd: flabby, NABS, soft, (+) epigastric and hypogastric tenderness Ext: full and equal pulses, no edema, no cyanosis ASESSMENT: NSTEMI CAD, Anteroseptal wall Ischemia NSR-E HCVD, LVH UTI Intestinal Parasitism (Hookworm) Plan: Admission NPO except meds IVF: PLRS 1L x KVO Labs: ECG, XR, 2D echo with Doppler, Trop I (Quanti), Na, K, Cl, Ca, Mg, PO 4, FBS, HDL, LDL, TG, TC, BUA, ABG, BUN, Crea, CBC with PC, UA, Serial PFA q6, PT, PTT, KUB-US Medications: Enoxaparine 0.6ml SC q12 ASA 80mg 4 tabs to chew then 1 tab OD per NGT Captopril 25mg tab ¼ tab TID per NGT Metoprolol 50mg ¼ tab BID per NGT Simvastatin 40mg OD per NGT Omeprazole 20mg OD per NGT if IV 40mg OD is not available Diazepam, 5mg IV q12 Lactulose 30cc at HS per NGT (deferred) Ofloxacin 200mg IV q12 ANST (deferred) Mebendazole 500mg PO per NGT x 1 dose Ceftriaxone 1g IV ANST Clarithromycin 500mg OD/NGT Hook to O2 at 4 lpm via nasal cannula, cardiac monitot VS q1, CBG q6, CBR without BRP U.O. monitoring Course at the wards: On the first hospital day, patient experienced chest pain (substernal), abdominal pain, edema, no change in bowel movement. Patient was conscious, coherent, not in cardio-respi distress. BP 150/90, CR 75, RR 28, T 36.7 and distended abdomen. Patient was maintained on NPO and NGT. IVF was PNSS 1L x KVO. Patient was on serial PFA and 12L ECG every 12 hours. Patient was scheduled for KUB ultrasound. If Enoxaparin was not available, patient was started on Heparin drip as follows: D5W 500cc + 1000 units heparin to run for 12 hours. Continue medications. Patient was applied for ICC for his antibiotics. Patient was placed in a moderate high back rest, complete bed rest with no bathroom previleges. Input and output was monitored. Patient’s vital signs were monitored every hour. On the second hospital day, PFA was discontinued. Abdominal On the seventh hospital day, patient had May go home orders with the following home medications: Coamoxiclav 625 mg tablet, 1 tablet Tid for 4 days Clarithromycin 500mg tablet, 1 tablet Bid x 4 days Tramdol 37.50 + Paracetamol 325 MG tablet Bid Vitamin K tablet, 1 tablet Tid PO Metoproplol 50mg tablet, ¼ tablet BID Enalapril 10 mg + HCTZ 12.5 tablet OD in AM Captopril 25mg tablet, 1 tablet SL for PRN of BP >160/100 Aspirin 80mg tablet, 1 tablet OD after lunch For x-ray of both feet AP, OPD basis. For request PT, ALT, AST, alkaline phosphatase, OPD basis. Advise for low salt, low fat diet to resume regular meal. Follow-up at OPD on Thursday 10 am, april 24, 2008. At rheuma clinic. Secure official CXR and ultrasound result.
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