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OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE Name: FLORES, ORLANDO S. Hospital #: 1565426 Age/Sex: 58/m Address: 1401 Adriatico St., Ermita Manila Date of admission: July 9,2007 Admitting Diagnosis: NSTEMI KII Hcvd,CAD, Cardiomegaly, Diffuse wall ischemia, CRBBB,QT E COPD prob emphysema Residents in charge: Drs. DalanonGutierrez/Gregorio Clerk-in-Charge: Ocampo/Reloj/Rosarito 48 HOUR HISTORY This is a case of a 58 year-old male who was admitted due to difficulty of breathing History of Present Illness 1 day PTC, patient started to experience difficulty of breathing. Patient has no chest pain, no fever, no cough, no abdominal pain. No consult was done and no meds taken. Few hours PTC, difficulty of breathing persisted. There was no loss of consciousness. Patient sought consult at a private hospital. Patient was given Hydralazine, but symptoms progressed hence patient consulted at OM, and was admitted. Past Medical History s/p, MI, 2006, OMMC, Maintains on ASA, ISMN, ISDA (+) asthma since childhood (+) COPD,2006,meds are Salbutamol + Ipratropium Br (-) DM No other previous hospitalizations Family History (+) asthma – paternal side Personal and Social History Smoker of 15 pack years Alcoholic beverage drinker Review of Systems N/A Physical Examination: General: Awake, irritable Vital Signs: BP:100/80 HR: 105 RR: 20 Temp: 36.5 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (+) distended neck veins CHEST AND LUNGS: symmetrical chest expansion, no retraction, (+) crakles , (-) wheezes HEART: adynamic precordium,PMI 6th ICS LMCL , no murmur, tachycardic ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: grossly normal, no cyanosis, no edema Assessment: NSTEMI KII HCVD, CAD, Cardiomegaly, Diffuse Ischemia, CRBB, ST, E COPD prob emphysema PLAN: For admission Course in the wards: On the first hospital day, the patient was admitted, and patient was placed on NPO temporarily. 12lead ECG with Doppler, and chest Xray were requested and performed, as well as laboratory tests – urinalysis, Na, K, Mg, LDL, HDL, cholesterol, triglycerides, FBS, BUN, Crea, CBC with Platelet count, ABG and BUA. Other laboratory test requested was CPK-MB every 6hours. Medications given were Enoxaparin 0.4ml SQ BID, ASA 80mg tab OD, Clopidogrel 75mg/tab OD/NGT, Captopril 25mg/tab TID/NGT, Metoprolol 50 mg 1tab BID, ISMN 30mg/tab BID/NGT, ISDN 5mg/tab SL for chest pain, Lactulose 30ml before bedtime (but was hold), Nalbuphine ½ amp TIV for severe pain, Diazepam 1 amp TIV as needed, Simvastatin 20mg/tab 1 tab OD PO, Omeprazole 40mg 1 cap TID OD and Salbutamol + Ipratropium Bromide nebulize every 6hours. Patient was hooked to a cardiac monitor and was advised to have a complete bedrest. Oxygen support was provided via a nasal cannula and patient was monitored every hour. nd On the 2 hospital day, vital signs: BP:80/50; HR: 136bpm; RR: 32cpm. 12-L ECG was done every 6 hours, dobutamine drip was started at 11-12ugtts/min. Patient was placed on NPO temporarily. Laboratory tests requested were CBG, repeat CPK-MB, PT, CT, BT. A 2D-echo with Doppler Ultrasound was requested to be done once the patient is stable. An NGT was inserted and subsequently he was intubated. Gastric lavage was done every 6hours. Previous medications were given except for Losartan which was shifted to Captopril 25mg/tab1/4 tabTID/NGT, Clopidogrel and Hydrocortisone were discontinued. Patient was continued to be monitored hourly.
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