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LOYOLA

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: LOYOLA, Cornelia Age/sex: 73/F Address: 2495 D. Espiritu St. Singalong, Manila Date of Admission: July 15, 2007 Admitting Diagnosis: PNEUMONIA, COMMUNITY ACQUIRED, MODERATE RISK CKD STAGE III 2O DM NEPHROPATHY DM 2 W/ NEUROPATHY CAD, HCVD, LVH, NSR, II-B R/O ACS S/P EGD X2 S/P AP (2003-OMMC) Residents-in-charge: Drs. Changco /Gardaya /delos Reyes-Gonzales /Filio /Indon Clerks-in-charge: Ocampo /Reloj /Rosarito CLINICAL ABSTRACT GENERAL DATA This is a case of a 73/F who came in due to abdominal pain.

Hospital Number:

HISTORY OF PRESENT ILLNESS: The patient is a diagnosed CKD St III secondary tro DM Nephropathy, maintained on Insulin (Humulin) 70/30 20 ’U’ at am 30 ‘U’ at pm. Pioglitazone 15mg tab OD. Patient is also a known CAD, HCVD maintained on ISMN, ISDN, Simvastatin, Clopidogrel. Patient was apparently well until 2 weeks prior to consultation when patient experienced difficulty of breathing. No abdominal pain, with back pain felt at the right side aggravated by deep breathing. There was no associated fever, no dysuria. There was cough with production of whitish phlegm. No consult done. 10 days PTC, above conditions persisted. Patient sought consult at OMMC with the diagnosis of CAP-LR and was given Clarithromycin 500mg tab BID. 1 week PTC, above conditions still persisted this time with abdominal pain that is non-radiating and crampy with a severity of 5/10. She self-meidcated with AlMgOH which afforded temporary relief. 1 day PTC, patient experienced generalized body weakness. Persistence of the above symptoms prompted consult. PAST MEDICAL HISTORY: s/p EGD x2 2005, 2001 at OMMC s/p AP 2003 at OMMC no BA FAMILY MEDICAL HISTORY: (+) DM and HPN on maternal side. PERSONAL and SOCIAL HISTORY: Non-smoker. Not an alcoholic beverage drinker. REVIEW OF SYSTEMS: Constitutional: no weight loss, anorexia, fever Skin: no pallor, no rashes, no jaundice HEENT: no blurring of vision, dysphagia, tinnitus, epistaxis Cardio: no chest pain, no PND, no orthopnea, no PND, no easy fatigability GIT: no diarrhea, no constipation, no melena, no hematochezia GUT: no dysuria, oliguria, hematuria, (+) nocturia Endocrine: (+) polydipsia, polyuria, no polyphagia, no tremors Hematology: no easy bruisability, no bleeding tendencies Musculoskeletal: no muscle or joint pains Neuro: no seizure, no loss of consciousness, no syncope PHYSICAL EXAMINATION: General Survey: Conscious, coherent

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Vital signs:

BP: 140/80

HR: 72 bpm

RR : 24 cpm

Temp: 36.5º C (axillary)

CBG: 95mg/dL

HEENT: anicteric sclera, pinkish palpebral conjunctiva, no naso-aural discharge, no cervical lymphadenopathy, no tonsillopharyngeal congestion, no mass, no neck vein engorgement Chest: Symmetric chest expansion, no lagging, no retractions, clear breath sounds, no egophony, crackles on the basal right lung field Heart: Adynamic precordium, PMI at 6th ICS LAAL, no heaves, no thrills, normal rate, regular rhythm, no murmurs Abdomen: flabby, normoactive bowel sounds, soft, non-tender, no mass Extremities: Grossly normal, no cyanosis, no jaundice, full and equal pulses ASSESSMENT: PNEUMONIA, COMMUNITY ACQUIRED, MODERATE RISK CKD STAGE III 2O DM NEPHROPATHY DM 2 W/ NEUROPATHY CAD, HCVD, LVH, NSR, II-B R/O ACS S/P EGD X2 S/P AP (2003-OMMC)

PLAN: Upon admission, patient was hooked on PNSS 1L x 12h. Diet was DM diet with SAP if not in respiratory distress. Laboratory exams requested were CBC w/ PC, UA, CXR-PA, ECG, FBS, BUN Crea, Na, K, HDL, LDL, BUA, TG, Chole, HgbA1C, Blood GS/CS x 2 sites. Medications prescribed were (1) Co-amoxiclav 1.2g TIV q8 ANST. (2) Clarithromycin 500mg tab BID. (3) ISMN 30mg tab BID PO. (4) ISDN 5mg tab SL prn for chest pains/anginal equivalents. (5) Simvastatin 20mg/tab ½ tab OD at HS. (6) Imidapril + HCTZ 10mg + 12.5mg tab OD. (7) Clopidogrel 75mg OD. (8) Pioglitazone 15mg tab OD. (9) Insulin (Humulin 70/30) SC 20 ‘u’ at am the n 15 ‘u’ at pm. (10) Regular insulin 5’U’ SC prn for CBG ≥ 250mg/dL. (11) Omeprazole 40mg TIV OD. (12) Gabapentin 30mg PO OD. (13) Vit. B complex cap OD. O2 via face mask was maintained. A 12L ECG was ordered for the following morning. Monitoring was VS q1, I&O CBG AC/HS. On the first hospital day

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