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PDS - DOC

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: VILLESTAS, JUANITO Age/Sex: 47/m Address: 163-C Lusito St., Sampaloc, Manila Date of admission: July 18, 2007 Admitting Diagnosis: NSTEMI KI CAD, HCVD, LVH, NSR, E Residents in charge: Drs. Magbiray /Gonzales /Filio /Indon Clerk-in-Charge: Ocampo/Reloj/Rosarito

Hospital #: 1711138

PATIENT DISCHARGE SUMMARY This is a case of a 47 year old male who came in due to chest pain History of Present Illness Patient is a previous diagnosed case of CAD, HCVD, previously admitted 3 times in Ospital ng Sampaloc with poor compliance to Metoprolol and ISMN. On prn ISDN and Nifedipine. Patient was apparently well until 3 hours prior to consultation around 3pm, he experienced sudden onset of chest, after eating while he was resting. It was graded as 7/10 in severity, non-radiating, squeezing in character. No dyspnea, no dizziness, no numbness of left upper extremity, no diaphoresis. Self-medicated with ISDN 5mg SL 1 tab which afforded temporary relief of chest pain. 30 mins PTC, still with chest pain 7/10 in severity, squeezing non-radiating. No dyspnea. Took ISDN5mg SL which did not provide relief hence consult in this institution, hence admission. Past Medical History 2000, 2004, 2005 – admitted in OsSam due to chest pain, diagnosed with CAD, HCVD. Diagnosed with HPN for 7 years. HBP 180/120, UBP 130/90. no allergy no operation GSW – occipital area – claimed to have retained Family History (+) HPN – paternal side (+) DM – mother and sibling Personal and Social History Smoker of 11 pack years Occasional alcoholic beverage drinker 1-2x/week x 20 years Review of Systems N/A Physical Examination: General: Conscious, coherent, not in distress Vital Signs: BP:110/80 HR: 110 RR: 18 Temp: 36.8 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (+) distended neck veins CHEST AND LUNGS: symmetrical chest expansion, no lagging, no retraction, no crackles HEART: adynamic precordium, PMI 6th ICS AAL , no murmur, tachycardic, regular rhythm ABDOMEN: globular, normoactive bowel sound, soft, non-tender, no mass EXTREMITIES: grossly normal, no cyanosis, no edema, full equal pulses. Assessment: NSTEMI KI CAD, HCVD, LVH, NSR, E PLAN: Patient was admitted at the ICU under the service of Drs. Magbiray/Gonzales/Filio/Indon. IVF hooked drip: 10 g ISDN + 90 cc D5W x 10 uggts/min. Titrate up to maximum of 30 uggts/min with BP precautions. NPO. I and O monitoring. Diagnostics requested are as follows: CBC c PC, UA, CXR PA, ECG q 6, CPKMB, BUN, Crea, Na, K, FBS, HDL, LDL, TG, Chole, BUN, 2D echo with Doppler. Medications are as follows: ASA 80 mg OD PO, Enoxaprine 0.4 ml BID SQ, Captopril 25 mg TID PO, Nalbuphine 1 amp TIV prn for severe chest pain, Diazepam 5 mg prn. O2 at 2-4 Lpm in nasal cannula. Hook to cardiac monitor. VSq1, CR full minute. WOF: DOB, hypertension. Ref. COURSE IN THE WARDS: 1ST hospital day, patient’s vital signs are as follows: BP100/70, HR22, CR36.8, (+) chest pain. NPO temporarily except meds. Maintan IVF on KVO. Isoket drip to follow: same rate with preparation. For 2D-echo with Doppler. Start Metoprolol 50 mg/tab ½ tab BID and Simvastatin 40 mg/tab OD. O2 support via nasal cannula. Vsq1, WOF chest pain, hypotension. Ref. 2nd hospital day, patient’s vital signs are as follows: BP 100/80, CR 70, RR 22, temp 37. Patient may have low fat, low salt diet with SAP. Maintain IVF. Isoket drip to consume. For 2D-echo with Doppler. May dangle legs. VSq1, WOF chest pain, dyspnea. Ref.

3rd hospital day, patient’s vital signs are as follows: BP 100/70, RR 20, HR 80, temp 37.1, no chest pain. Low fat and low salt diet with SAP. Discontinue IVF. Still for 2D-echo with Doppler. May wear from O2 support. VSq1, WOF dyspnea and chest pain. May walk arounf bed. Discontinue CBG monitoring. Ref. May transfer to infirmary under the service of Drs. Magbiray/Belgua/Gonzales/Filio/Indon. Patient still for FBS, chole, TG, HDL, LDL, BUA. VSq1. Ref. 4th hospital day, was discharged. Home meds are as follows: Enoxaprine 0.4 ml SQ 2x a day x 3 more days; ASA 80 mg/ tab OD after lunch. Captopril 25 mg/tab TID; Metoprolol 50 mg ½ tab BID; Simvastatin 40 mg/ tab OD at HS; ISDN 5 mg 1 tab TID PO; Multivitamins 1 tab OD. For FBS, chole, TG, HDL, LDL, BUA on OPD basis. Follow up IM-OPD on Tuesday 1 pm. Advised. LABORATORY RESULTS: Lipid Profile 07/19/07 TEST NAME Triglycerides Cholesterol HDL Glucose Uric acid LDL

RESULT 1.26 5.90 0.90 4.93 0.33 4.43

LOW

HIGH

UNITS mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L

NORMAL VALUES 0.34 – 1.70 5.20 – 6.20 1.00 – 1.60 3.90 – 6.10 0.11 – 0.43 1.10 – 3.80

Urinalysis PHYSICAL: COLOR: Light yellow TRANSPARENCY: clear MICROSCOPY: EPITH. CELL: few MUCUS THREAD: few AMORPH. URATES: occasional PUS CELLS: 1-3/hpf ERYTHROCYTES: 0-1/hpf AMORPH. PHOSPHATE: BACTERIA: CALCIUM OXALATE: few URIC ACID: YEAST CELLS: CAST: CHEMICAL: ALBUMIN: (-) SUGAR: (-) SPECIFIC GRAVITY: 1.015 pH: 6.0 Clinical Chemistry TEST NAME Blood Urea Nitrogen Creatinine Sodium Potassium RESULT 3.79 69 142 4.2 UNITS mmol/L mmol/L mmol/L mmol/L NORMAL VALUES 2.60 – 6.40 53.00 – 115.00 140.00 – 148.00 3.60 – 5.20

Chemistry Tests CK - MB Results 147 U/L Normal Range 0 - 16

HI

Hematology WBC RBC HGB HCT MCV MCH MCHC PLATELET 8.6 4.66 133 0.413 88.6 28.6 323 167 4.8 – 10.8 x 10^9 /L 4.0 – 6.20 x 10^12/L 14 – 18 g/dL 42 – 52 % 81 – 99 fL 27 – 31 32 – 36 150 – 400 x 10^9/L NEUTROPHILS LYMPHPCYTES MONOCYTES EOSINOPHILS BASOPHILS CT BT ESR 0.777 0.179 0.038 0.006 0.000 0.500 – 0.700 0.200 – 0.500 0.020 – 0.090 0.000 – 0.060 0.000 – 0.020 0 – 10 mm/hr


								
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