OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: DE LOS SANTOS, DANILO Age/sex: 58/M Address: 2172 Road 2 Palace Est. Sta. Ana, Manila Date of Admission: July 10, 2007 Admitting Diagnosis: AMI KI HCVD, CAD, Anteroseptal Wall MI, E Residents-in-charge: Dr. Torres/Dr. Dalanon/Dr. Roxas/Dr. Estrada Clerks-in-charge: Ocampo, L./Reloj, J./Rosarito, M.
Hospital Number: 1707757
CLINICAL ABSTRACT GENERAL DATA This is a case of a 58-year-old female from Sta. Ana, Manila who came in due to chest pain and back pain. HISTORY OF PRESENT ILLNESS: One hour prior to admission, patient experienced chest pain, radiating to leftarm, persistent, not relieved by rest and intake of medications. There were no associated symptoms of abdominal pain, cough, fever, loss of conciousness and dysuria, however, patient also experienced difficulty of breathing. Persistence of above symptoms prompted consult and subsequent admission at IM-OMMC. PAST MEDICAL HISTORY: (+) hypertension (+) DM No other previous hospitalization nor operation FAMILY MEDICAL HISTORY: (-)HPN; (-)DM; (-)Asthma; (-)Heart disease No other heredofamilial diseases PERSONAL and SOCIAL HISTORY: Smoker, Alcoholic beverage drinker REVIEW OF SYSTEMS: Constitutional: No fever, no weight loss, no chills, no loss of appetite Skin: no pallor, no rashes, no jaundice HEENT: no tinnitus, no diplopia, no blurring of vision, no epistaxis, no dysphagia, no hoarseness Cardio: no chest pain, no palpitations, no PND, no orthopnea, no easy fatigability GIT: no changes in bowel movement, no melena, no hematochezia 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: Awake, conscious, coherent, in cardiorespiratory distress Vital signs: BP: 110/80 mmHg RR : 20 cycles / minute HR: 98 beats / minute Temp: 37º C (axillary)
Skin: No jaundice, good skin turgor HEENT: anicteric sclera, pink 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 Heart: Adynamic precordium, PMI at 6th ICS LMCL, normal rate, regular rhythm, no murmurs Abdomen: flabby, normoactive bowel sounds, soft, non-tender Extremities: Grossly normal, no cyanosis, no jaundice, full and equal pulses ASSESSMENT: AMI KI HCVD, CAD, Anteroseptal Wall MI, E Course in the wards: The patient was admitted under the service of Dr. Torres/Dr. Dalanon/Dr. Roxas/Dr. Estrada. Patient was put on NPO temporarily and hooked to plain NSS on KVO. Laboratory and diagnostic exams requested were CBC with platelet count, chest Xray, 12-L ECG, urinalysis, and serum BUN, creatinine, Na, Ca, Mg, HDL, LDL, triglycerides, cholesterol and 2-D Echo with Doppler. Medications were given: Streptokinase 1.5M IU in 90 ml D5W x 1hour; Heparin 3600 U bolus then D5W 500ml + 8600 U x 12 hours; ASA 80g 1 tab OD PO; Clopidogrel 75mg/tab OD
PO; Captopril 25mg 1 tab TID PO; Metoprolol 50mg 1 tab BID PO; ISMN 30mg 1 tab BID PO; ISDN 5mg 1tab SL for chest pain; Nalbuphine ½ amp TIV for severe pain; Diazepam 1 amp TIV prn; Simvastatin 20mg 1 tab OD PO and Omeprazole 40mg/amp TIV OD. Patient was hooked to cardiac monitor, was advised to have a complete bed rest and was maintained on mod-high back rest. He was also maintained on oxygen support via nasal cannula at 2-4rpm. Vital signs were monitored every hour, to watch out for chest pain, dyspnea; also CBG was monitored every 6hours. Vital signs: BP-110/80mmHg, HR-54, RR-19, Temp.-36.1 and CBG: 160mg/dl. On the first hospital day, vital signs: BP-110/80mmHg, HR-54, RR-19, Temp.-36.1.Patient was placed on NPO temporarily, heparin drip TF: same rate and preparation. ASA was secured and given. Omeprazole IV was shifted to Lansoprazole 30mg/tab OD. ISDN 5mg/tab was put on hold and given only if with SBP of <90mmHg; was maintained on mod-high back rest. Vital signs were monitored every hour, to watch out for chest pain, dyspnea and hypoglycemia; also CBG was monitored every 6hours. On the 2nd hospital day, vital signs: BP-90/60mmHg, HR-52, RR-22, Temp.-36.7. Patient was placed on soft diet with SAP. Heparin drip was still continued. Patient was requested to undergo 2D-Echo with Doppler once stabled. CBG monitoring was decreased to HS. Oxygen support can be removed. Vital signs were monitored every hour, to watch out for chest pain, dyspnea and hypoglycemia. On the 3rd hospital day, vital signs: BP-90/60mmHg, HR-50, RR-22, Temp.-36.7. Patient was still placed on soft diet with SAP. IVF TF: D5W500 x KVO. Patient was still for 2D-Echo with Doppler once stabled. CBG monitoring HS. Labs requested were: repeat PTT, FBS, CK-MB; for SGPT, SGOT, Alk. Phosphate, UTZ of HBT. Patient was started on Vit. K 1 amp every 8 hours. Vital signs were monitored every hour, CR and RR full minute, to watch out for chest pain, dyspnea. On the 4th hospital day, vital signs: BP-110/60mmHg, HR-64, RR-19, Temp.-36 and CBG: 120mg/dl. Patient was still placed on soft diet with SAP. IVF was continued. Patient was still for 2D-Echo with Doppler once stabled. CBG monitoring HS. Vital signs were monitored every hour, CR and RR full minute, to watch out for chest pain, dyspnea. On the 5th hospital day, vital signs: BP-100/60mmHg, HR-72, RR-20, Temp.-36. Patient was still placed on soft diet with SAP. IVF may be shifted to heplock. Patient was still for 2D-Echo with Doppler once stabled. CBG monitoring HS. Gliclazide 80mg/tab OD was given. Vital signs were monitored every hour.
Summary of Laboratory exams: Complete Blood Count WBC RBC Hgb Hct MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphus Urates Pus Cells Erythrocytes Albumin Sugar Sp gravity pH July 10, 2007 Amber Slightly turbid Moderate Moderate Moderate 3-5/hpf 6-9/hpf +3 Negative 1.030 6 Normal Values 4.8-10.8 x 109 /L 4.0-6.20 x 1012 /L 12-16g/dl 37-47 % 80-90 fL 27-31 32-36 150-400 x 10^9/L 55-57 20-30% 0-7% 0-3% 0-1% July 10, 2007 14.3 4.0 13.2 39.3 98.3 33. 2 33.7 224 74 17.3 5.7 2.6 0.4
Blood Chemistry Normal Values FBS BUN 2.5 - 7.10 mmol/L Creatinine 53 – 115 umol/L Uric acid 178-345 umol/L Sodium 140-148 mmol/L Potassium 3.6 – 5.2 Chloride 100-108 mmol/L
July 10, 2007 3.66 111.02 390.28 138.60 Normal Normal High Normal
Prothrombin time % Activity INR Control Prothrombin time APTT
Normal Values 11.0 -14.0 secs 11.5 – 15.5 secs 11.0 -14.0 secs 35.5 secs
July 10, 2007 32.5 17% 3.24 14.7 11.7 33.0
Normal Values Albumin Adult total bilirubin Adult direct bilirubin Adult indirect bilirubin Alkaline phosphatase AST ALT Glucose 34-50 g/L 3-22 umol/L 0-7 umol/L 0-19 umol/L 50-136 U/L 15-37 U/L 30-85U/L 3.90-6.10 mmol/L
July 10, 2007 35 10.70 0.90 9.80 53 139 HIGH 62 7.79 mmol/L HIGH 13 U/L
Normal: 0-24 U/L