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PADOLINA - DOC

VIEWS: 18 PAGES: 3

									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: PADOLINA, Carlos Age/sex: 84/M Address: 2190 F. Balagtas St., Pandacan, Manila Date of Admission: June 14, 2007 Admitting Diagnosis: Pneumonia in immunocompromised host, Bronchogenic CA BPH COPD in acute exacerbation Residents-in-charge: Dr. Clerks-in-charge: Villanueva/Villarama/Ybañez CLINICAL ABSTRACT GENERAL DATA This is a case of an 84-year-old male from Pandacan, Manila, who came in due to pleuritic chest pain

Hospital Number: 1697838

HISTORY OF PRESENT ILLNESS: Patient is a diagnosed case of lung cancer (SCCA), COPD 2006 at OMMC, with medications: Patient was apparently well until… 4 days prior to admission, patient experienced pleuritic chest pain associated with productive cough and fever. There was no orthopnea, no PND, no palpitation, no hemoptysis. No consult was done, and medications were continued. Few hours prior to admission, patient’s symptoms persisted and severity of pain occurred, prompting consult at our institution. PAST MEDICAL HISTORY: (+) hypertension (+) CAD with medications:

Candesartan + HCTZ ISDN ISMN Nicorandil Clopidogrel

(-) DM (-) Bronchial asthma (-) PTB (-) allergies FAMILY MEDICAL HISTORY: (+) hypertension on the paternal side (-) other heredofamilial diseases PERSONAL and SOCIAL HISTORY: Patient is a smoker of 80 pack years and occasional alcoholic beverage drinker REVIEW OF SYSTEMS: Constitutional: with weight loss of about 50% in a year, no chills, no loss of appetite Skin: no pallor, no rashes, no jaundice, no itching HEENT: no tinnitus, no blurring of vision, no epistaxis, no dysphagia, Cardio: no chest pain, no palpitations, no PND, no orthopnea, no easy fatigability GIT: no changes in bowel movement, no melena GUT: no dysuria, no oliguria, no hematuria, no nocturia Endo: no polyuria, polydipsia, polyphagia, Hema: no easy bruisability, no poor wound healing, no gum bleeding Neuro: no seizures; no loss of consciousness Musculoskeletal: no weakness, no myalgia, no athralgia PHYSICAL EXAMINATION: Conscious, coherent, not in cardiorespiratory distress Vital signs: BP: 120/70 mmHg HR: 70 beats / minute RR: 26 cycles / minute Temp : 36.7º C (axillary) Skin: No jaundice, good skin turgor HEENT: anicteric sclera, pale 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, (+) bibasal crackles, (+) wheeze Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: flabby,, normoactive bowel sounds and non-tender Extremities: (+) clubbing, no cyanosis, no jaundice, full and equal pulses Neuro: Patient oriented to three spheres CN I – Intact CN II – Pupils equally reactive to light and accommodation 2-3mm CN III, IV, VI – EOM’s intact CN V – (+) corneal reflex CN VII – No facial asymmetry CN VIII – intact CN IX, X – good gag CN XI – Good shoulder shrug CN XII – tongue at midline

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MOTOR RUE – 5/5 LUE - 5/5 RLE – 5/5 LLE – 5/5 ASSESSMENT:

SENSORY RUE – 100% LUE - 100% RLE – 100% LLE – 100% Pneumonia in an immunocompromised host Pulmonary CA (squamous cell carcinoma) COPD in acute exacerbation CAD, LVH, NSR, II-B BPH

DTR RUE ++ LUE ++ RLE ++ LLE ++

Plan: For admission Course in the wards: Patient was admitted into the Infirmary ward and hooked to IVF of plain NSS. Diagnostic and laboratory exams requested were 12-lead ECG, chest Xray, CBC with platelet count, sputum GS/CS, blood CS x 2 sites, blood typing, urinalysis, arterial blood gases, and serum sodium, potassium, and chloride.

Summary of Laboratory exams:

Complete Blood Count Normal Values 6/27/07 6/27/07 WBC 4.8-10.8 x 109 /L 15.9 15.2 RBC 4.0-6.20 x 1012 /L 3.2 2.8 Hgb 12-16g/dl 9 8.1 Hct 37-47 % 27.7 24.6 MCV 80-90 fL 87.7 88.1 MCH 27-31 28.6 28.3 MCHC 32-36 33 32 Platelet 150-400 x 10^9/L 316 342 Neutrophils 55-57 92.2 90.7 Lymphocytes 20-30% 3.8 6.3 Monocytes 0-7% 3.4 2.1 Eosinophils 0-3% 0.6 0.9 Basophils 0-1% 0 Hypochromia: (+); Anisocytosis: (+++); Poikilocytosis (+); TG (-) Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphus Urates Pus Cells Erythrocytes Cast Albumin Sugar Sp gravity pH bacteria Yeast cells 6/14/07 Dark yellow Turbid Many Few Occasional 18-22/hpf 1-3/hpf Hyaline cast 2-4/hpf Fine granular cast 0-2 +1 Negative 1.030 6.0 6/25/07 Light yellow Slightly turbid Occasional Few Few 0-2 1-2 6/27/07 Amber Turbid Few Occasional Moderate Many Abundant 6/29/07 13.7 3.7 10.6 31.7 86.0 28.7 33 325 94.2 1.6 3.2 0.8 0.2 11.7 4.4 12.6 38.3 86.8 28.7 33 224 82.7 11.1 4.8 1.3 0.1 7/4/07

Trace Negative 1.025 6.5 many

+1 Negative 1.025 6.0 Many

Bacteriology Specimen Microscopy 7/2/07 Tracheal aspirate (+) Pus cells (+) gram positive cocci in pairs Few gram positive cocci in clusters few colonies of Staphylococcus epidermidis (not significant) 7/3/07 Blood

Culture

Positive for Pseudomonas aeruginosa after 1 day of incubation

Immunopathology Test Trop I quantitative (6/27/07) Blood Typing FORWARD TYPING Anti-A Anti-B pos neg ABO type: A Rh type: positive

Reference value 0-0.16 ug/L

Results 0.14

RH TYPING Anti-D pos

REVERSE TYPING Known A Known B

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Blood Chemistry Normal Values BUN Creatinine Glucose Uric acid 2.5 - 7.10 mmol/L 53 – 115 umol/L 3.9-6.4 mmol/L 202-416.5 (male) 142.8-339.2 (female) 2.12-2.52 0.85-1.05 140-148 mmol/L 3.6 – 5.2 100-108 mmol/L 35 – 120 U/L 66-87 g/L 34-48 g/L 20-38 g/L 6/14/07 11.9 94.57 8.7 692.15 6/27/07 (7:51) 6/27/07 (18:50) 5.25 83 6/30/07 (12:51am) 6/30/07 (12:10pm) 7/2/07

Calcium Ionized calcium Sodium Potassium Chloride Alk phos Total protein Albumin S. Globulin

1.38 0.80 138 2.9 144 2.6 2.80 5.50 3.7

100.25 73.51 27.08 46.43

Arterial Blood Gas 6/14/07 pH pCO2 pO2 HCO3 TCO2 BEb ABEc SBEc O2 Sat tO2e 95.20% 7.416 32.90 75.00 21.30 22.30 -1.8

6/27/07 (07:19) 7.439 21.50 229.00 14.70 15.40 -6.5

6/27/07 (15:49) 7.484 18.80 150.00 14.20 14.80 -5.9

6/28/07 7.451 22.40 114.00 15.80 16.50 -5.4

6/29/07 7.505 22.10 115.0 17.60 18.20 -2.7

6/30/07 7.518 23.30 114.00 19.10 19.80 -1.2

7/2/07 7.543 21.5 98.2 18.1

7/3/07 7.521 20.30 100.00 16.80 17.40 -3

7/4/07 7.521 25.70 65.00 21.30 22.00 0.5

7/6/07 7.508 31.70 111.00 25.40 26.40 3.5

99.80%

99.5%

98.80%

99.00%

99.00%

-2.2 mmol/L -4.2 mmol/L 98.1% 20.6% vol

98.60%

95.00%

98.90%

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