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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE \

Name: BOLIVAR, RICARDO Age/Sex: 74/M Address: 2961 L. dela Paz Pandacan Manila Date of admission: August 5, 2007 Admitting Diagnosis: Community acquired pneumonia, moderate risk COPD in acute Exacerbation HCVD, LVH, NSR, II B Osteoarthritis right shoulder Residents in charge: Drs. Payumo/Aguila/Receno/Dimaandal Intern-in-Charge: Ryan Escandor Clerk-in-Charge: Palay/Rentillo/Roxas

Hospital #: 1715918

48 hour history This is a case of a 74 year-old male who came in due to difficulty of breathing History of Present Illness 2 mos PTA, patient had productive cough with yellowish sputum and occasional dyspnea spontaneously resolved. No associated chest pain nor fever. No consult done. No meds taken. 1 month PTA, condition persisted still with no associated ssx. Still no consult done and no meds taken. 2 wks PTA, still with cough, with yellowish sputum still with no fever but with occasional pleuritic chest pain. And dyspnea which is still spontaneously resolved. No consult done, no med taken. 1 wk PTA, still with persistence of condition and still no consult doe nor medication taken. 2 days PTA, had consulted IM ER due to persistence of condition. NEbulization was done and afforded relief diagnosed with COPD. Meds given were Combivent nebulization, Doxophylline, tiotropium but with poor compliance. No associated fever and sent home after relieved from ssx. Few Hrs PTA, (+) severe dyspnea he still have productive cough with no fever noted. Persistence prompted consult hence the admission. Past Medical History (+) PTB – diagnosed 6 months ago in a health center. Completed 5 months of PTB drugs due financial constraint (+) HPN - x 34 years HBP 170/90, UBP 150/90 on calcibloc with poor compliance No previous operations No allergy Family History (+) HPN, BA father and mother side (+) PTB father side Personal and Social History 36 pk-year smoker and an alcoholic beverage drinker, 4-6x/wk: 1 bottle of gin bilog /session x >30 years. Review of Systems Constitutional: (-) anorexia, (+) weight loss 10% in 2 mos HEENT: (-) headache (-) dizziness (-) dyshagia (-) (+) hoarseness (+) BOV, (-) tinnitus Cardiovascular: no palpitation, with orthopnea, no PND GIT: no abdominal pain, no LBM, (-) melena GUT: no dysuria, oliguria, hematuria Endocrine: no 3Ps HEmatologic: no easy brusability MSS: (+) right shoulder pain on movt. No myalgia NEurologic: no LOC, no seizure Physical Examination: Conscious, coherent, in distress Vital Signs: BP: 130/80 HR: 108 RR: 32 Temp: 36.7 Skin: no pallor, no cyanosis HEENT: pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no mass, no neck vein engorgement, no nasoaural discharge, no cervical lymphadenopathies CHEST AND LUNGS: symmetrical chest expansion, + intercostal retraction, no lags, (+) diffuse crackles (+) wheeze right mid to basal lung HEART: adynamic precordium, PMI at 6th ICS AAL, tachycardic, RR, no murmur ABDOMEN: flat, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: full equal pulses, no edema, no cyanosis, (+) pain on active movement of right shoulder Assessment: Community acquired pneumonia, moderate risk COPD in acute Exacerbation

HCVD, LVH, NSR, II B Osteoarthritis right shoulder PLAN: For admission Patient was admitted to the service of Drs. Aguila, Receno, and Dimaandal. Consent for admission and management was secured. She was hooked to IVF: PNSS 1L x 12 hours to be followed by another PNSS 1L x 12 hours. May have soft diet with SAP. NGT was inserted. Laboratory procedures requested were CBC with platelet count, urinalysis, CXR PA, ECG, ABGs, FBS, BUN, creatinine, Na+, K+, HDL, LDL, TG, cholesterol, BUA, Blood CS/ Sputum GS.CS. Medications ordered were Ceftriaxone 1g TIV, Azithromycin 2g PO SD, Salbutamol + Ipratropium nebulization q4, Doxophylline 400mg BID PO, Insulin 50mg OD PO, Clonidine 75mg SL PRN for BP ≥160/100. He is on a moderate to high back rest. O2 was given at 6 lpm via nasal cannula. VS monitiored q1. Upon admission, patient is placed on NPO while dyspneic. Maintained on IVF. Previously ordered labs were still requested Medications were continued and other medications added were tiotropium 18 mcg/cap 1 tab OD, Salbutamol + Fluticasone250mcg 2 puffs BID, tramadol 50 mg 1 cap BID PRN for pain. He is still on a moderate high back rest. VS monitored q1 with WOF dyspnea and cyanosis. Chest physiotherapy is advised after nebulization On the 1st hospital day, stable vital signs but is tachypneic with RR of 27 and diffuse bilateral crackles. He was placed to low salt low fat diet with IVF: PNSS 1L x 8 hours. Other labs were still requested. Nebulization continued. Medications were continued. He is placed on a moderate to high back rest. Personal hygiene is advised. O2 support maintained. VS monitored q1 with I and O monitoring with WOF DOB and cyanosis. Chest Physiotherapy after nebulization is advised. At around 6 pm, vital signs were stable but is still tachypneic with RR 25. He was still placed to low salt low fat diet with IVF: PNSS 1L x 8 hours. Other labs were still requested. Nebulization continued q6. Medications were continued. He is placed on a moderate to high back rest. O2 support maintained. VS monitored q2 with I and O monitoring with WOF DOB and cyanosis. Chest Physiotherapy after nebulization is advised. On the 2nd hospital day, He was still placed to low salt low fat diet with IVF: PNSS 1L x 8 hours. Other labs were still requested. Nebulization continued q6. Medications were continued. He is placed on a moderate to high back rest. O2 support maintained. VS monitored q2 with I and O monitoring with WOF DOB and cyanosis, respiratory distress. Chest Physiotherapy after nebulization is advised. At around 7:30 pm, He was still placed to low salt low fat diet with IVF: PNSS 1L x 8 hours. Other labs were still requested. Nebulization continued q6. Medications were continued. He is placed on a moderate to high back rest. O2 support maintained. VS monitored q2 with I and O monitoring with WOF DOB and cyanosis, respiratory distress. Chest Physiotherapy after nebulization is advised. AM drip: 500 mg aminophylline in 500ccand D5W x 16-17 ugtts/min to WOF seizure and arrhythmia. On the 3rd hospital day, the patient is conscious and coherent with BP of 130/80 CR 75 RR20 T37, with crackles and wheeze on bilateral lung field. HE is still on a low salt low fat diet and was hooked to IVF with APL drip at 16-17 ugtts/min. other meds available were continued. He is still on a moderate to high back rest to WOF cyanosis, DOB and chest pain. Vital signs monitored every 2 hours with I and O monitoring and CBG monitored every 8 hrs. O2 support via nasal cannula was maintained with nebulization continued every 6 hrs.


				
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