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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 Clerks-in-Charge: Ocampo/Reloj/Rosarito

Hospital #: 1715918

Patient Discharge Summary 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. At 5:45 pm, BP was 140/90, CR 84, RR 25, Temp 37, still with crackles and occasional wheeze, the patient is still on a low salt low fat diet. APL drip was continued. Other labs requested were followed up. Medications were continued. Vital signs monitored every 2 hours with I and O monitoring, O2 support maintained to WOF respiratory distress. On the 4th hospital day, the patient is conscious and coherent with BP was 140/80, CR 81, RR 20, Temp 37, still with crackles not associated with DOB nor cyanosis, the patient is still on a low salt low fat diet with strict aspiration precaution. APL drip was continued at same preparation at 16-17 ugtts/min. Other labs requested were followed up such as sputum AFB x 3 days, sputum GS/CS and rpt CBC with platelet. Ceftriaxone per ICC was ordered to be secured. Doxophylline was on hold. Nebulization continued every 6 hours. Medications were continued. Patient still on moderate to high back rest. Vital signs monitored every 2 hours with I and O monitoring, O2 support maintained to WOF DOB and cyanosis. At 7 pm, BP was 130/80, CR 85, RR 20, Temp 37, no DOB nor cyanosis, the patient is still on a low salt low fat diet with strict aspiration precaution. APL drip was continued at same preparation at 16-17 ugtts/min. Other labs requested were followed up. Nebulization continued every 6 hours. Medications were continued. Patient still on moderate to high back rest. Vital signs monitored every 2 hours with I and O monitoring, and CBG monitored AC/HS. O2 support maintained and to WOF DOB and cyanosis. On the 5th hospital day, BP 130/70, CR 80, RR 22, Temp 37, still with crackles not associated with DOB nor cyanosis, the patient is still on a low salt low fat diet. APL drip was continued at same preparation at 16-17 ugtts/min. Other labs requested were followed up. May give Co amoxiclav 625mg tab 1 tab TID if Ceftriaxone is NA. Nebulization continued every 6 hours. Medications were continued. Patient still on moderate to high back rest. Vital signs monitored every 1 hours with I and O monitoring, O2 support maintained to WOF DOB and cyanosis. At 7: 15, BP 130/80, CR 86, RR 27, Temp 36.8, still with crackles not associated with DOB nor cyanosis, the patient is still on a low salt low fat diet. IVF reinserted with APL drip to follow at same preparation at 16-17 ugtts/min. Other labs requested were followed up. Nebulization continued every 6 hours. Medications were continued. Patient still on moderate to high back rest. Vital signs monitored every 2 hours with I and O monitoring, O2 support maintained to WOF DOB and cyanosis. On the 6th hospital day, the patient is conscious and coherent with BP was 180/100, CR 98, RR 24, Temp 37, still with crackles not associated with DOB nor cyanosis, the patient is still on a low salt low fat diet with strict aspiration precaution. APL drip was continued at same preparation at 16-17 ugtts/min. Other labs requested were followed up such as sputum AFB x 3 days and, sputum GS/CS. May give nifeipine with BP ≥160/100. Nebulization continued every 6 hours. Medications were continued. Patient still on moderate to high back rest. Vital signs monitored every 2 hours with I and O monitoring, CBG AC/HS. O2 support maintained to WOF DOB and cyanosis. At 8: 20 pm, BP was 120/80, CR 80, RR 20, Temp 37, no DOB nor cyanosis, the patient is still on a low salt low fat diet with strict aspiration precautiotn. APL drip was continued at same preparation at 16-17 ugtts/min. Other labs requested were followed up. Ceftriaxone per

ICC was ordered to be secured. Doxophylline was on hold. Nebulization continued every 6 hours. Medications were continued. Patient still on moderate to high back rest. Vital signs monitored every 2 hours with I and O monitoring, CBG AC/HS. O2 support maintained to WOF DOB and cyanosis. On the 7th HD, BP was 120/80, CR 71, RR 21, Temp 37, no DOB nor cyanosis but still with crackles. Patient still on a low salt and low fat diet. Laboratory results were followed up. Patient was scheduled for a repeat chest x-ray. Previous management and medications were continued, Paracetamol 300mg/amp 1 ½ amp TIV every four hours for temperature > 38 Celsius; and was advised to do TSB. Vital signs monitored every 2 hours with I and O monitoring, CBG every 6 hours. O2 support maintained to WOF DOB and cyanosis. On the 8th HD, patient was conscious and irritable, diaphoretic, still with crackles on the BLF. BP was 130/90, CR 89, RR 32, Temp 38, no DOB nor cyanosis but still with crackles. She was intubated and was for continuous ambubagging, since they cannot provide for a mechanical ventilator. Patient was placed on NPO. New laboratories were requested: CXR-PA, ABGs, CBC and 12LE, CG. Impression: ARF secondary to CAP On the 9th hospital day, patient’s ET tube was out, and there was tight air entry. Patient was dyspneic, shallow and rapid respiration, and with intercostals retractions. Patient was reintubated with continuous ambubagging. NGT was also inserted. Patient was maintained on NPO and was transferred to room 424. Medications available were continued. Patient was started on Sucralfate 1 gram/tab every 6 hours. Patient was maintained on moderate back rest, VSq1 with CR and RR full minute, CBG q4, suction secretions q1 and prn. After 2 hours, patient self-extubated. Patient was then maintained on O2 support with face mask at 10 lpm. Patient’s vital signs were as follows: 120/80, 72, 24, 37.2, (+) crackles, no retractions, no cyanosis. Monitoring were the same. Patient was watched out for tachycardia, tachypnea, SBP<90mmHg, cyanosis. On the 10th hospital day, patient was conscious and coherent, with vital signs as follows: 140/90, 98, 38, 38.1, (+) crackles on BLF, no cyanosis. Patient was maintained on O2 support via nasal cannula. Medications available were continued. Patient was on vsq1 monitoring with CR and RR full minute, CBG q6. Watch out for respiratory distress and cyanosis. On the 11th hospital day, patient had DOB, cough, and fever. BP was 150/70, CR 90, RR 34 gasping and temperature was documented to be 38 C. There is retractions, crackles in both lung fields, and dynamic precordium. Patient was ordered to be transferred at room 424 and was ordered to be intubated and be hooked to a mechanical ventilator or do ambubagging at 10 lpm. Patient was for ABGs, CXR, and repeat CBC. However, patient refused to be intubated and signed a consent regarding his refusal. Patient then was hooked to face mask at 10 lpm. Nebulization was continued. Patient was monitored vsq1, CR and RR full minute. Patient is watched out for cyanosis and respiratory distress. SUMMARY OF LABORATORY RESULTS

CBC WITH PC WBC RBC HGB HCT MCV MCH MCHC PLATELET NEUTROPHIL LYMHOCYTES MONOCYTES EOSINOPHILS BASOPHILS BLOOD CHEMISTRY FBS TG Cholesterol Potassium

04 Aug 2007 (Initial) 10.7 x 109/L 4.2 x 1012/L 12.4 mg/dL 37.3 % 88.8 fL 29.5 33.2 348 x 109/L 92.7% 2.6 % 3.1 % 1% 0.6%

04 Aug 2007 (Post BT1hr) 16.2 x 109/L 2.9 x 1012/L 9.2 mg/dL 24.2 % 82.9 fL 31.7 38.2 301 x 109/L 81.2% 8.4 % 6.7 % 3.2 % 0.5%

09 Aug 2007 4.9 x 109/L 3.4 x 1012/L 10.3 x mg/dL 30.9% 92.4 fL 30.7 33.2 327 x 109/L 70.8% 16.8% 6.4% 5.5% 0.5%

08 Aug 2007 10.2 mmol/L 1.35umol/L 3.33 mmol/L 3.9 mmol/L

URINALYSIS (06 Aug 2007) Physical Color: yellow Transparency: Clear Microscopic Epith Cell occasional Mucus Thread occasional Amorph Urates occsional Pus Cells 0-2 /hpf Erythrocytes 8-9/hpf

Cast:

Chemical Albumin: +4 Sugar: negative Specific Gravity: 1.03 pH:7

CHEST XRAY RESULT Basal pneumonia, right Cardiomegaly Atheromatous aorta Pleural effusion and or thickening, right


				
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