Ospital ng Maynila Medical Center Department of Internal Medicine
Name: Estepa, Juanita Age/Sex: 83/F Address: 1519 Eusebio st. Pandacan, Manila Date of admission: July 20, 2007 Admitting Diagnosis: ACS prob NSTEMI KI CAD, HCVD, LVH, AF with SVR-MVR, IV E Physicians-in-charge: Dr. Magbiray/Caole/Torres/Roxas/Estrada CIC: Ocampo, L./Reloj, J./ Rosarito A.
Hospital No.: 1711460 Room #: ICU bed 3 Date of Discharge: Final Diagnosis:
48-HOUR HISTORY The patient is a diagnosed case of CAD, MCVD at OMMC last 2005. Maintained on ISDN, ASA, Metoprolol, and digoxin with good compliance. History of Present Illness 1 day PTA, no DOB, no fever, no anorexia, no vomiting, (+) chest heaviness, no abdominal pain. Meds continued. No consult was done. Few hours PTA, persistence of above condition with increase severity of DOB. No cyanosis, no seizure. Past Medical History (+) CAD, HCVD x 2 years – OMMC (-) DM (-) BA (-) allergies Family History No DM No HTN No BA Personal and Social History Non-smoker, non-alcoholic beverage drinker Review of Systems General: no weight loss, no fever, no loss of appetite HEENT: no blurring of vision, no headache, no epistaxis, no dysphagia Respiratory: no cough, no colds Gastrointestinal: no abdominal pain, no change in bowel movement Genitourinary: no urinary frequency, no dysuria, no hematuria, no oliguria Endocrine; no polyuria, no polydipsia, no polyphagia Hematologic: no easy bruisability, no bleeding tendency Neurologic: no headache, no vomiting, no loss of consciousness Physical Examination: Conscious, coherent, in respiratory distress Vital Signs: BP 180/80 HR: 108 RR:28 Temp: 36.7 C
HEENT: pink palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds th HEART: adynamic precordium, PMI at 6 ICS LAAL, normal rate, irregular rhythm, with murmur
ABDOMEN: flabby , normoactive bowel sounds, soft, nontender EXTREMITIES: grossly normal extremities, no cyanosis, no edema.
Neuro: Patient is stupurous CN I : N/A CN II: pupils 2-3 cm equally reactive to light, (+) direct and consensual reflex CN III, IV, VI: intact doll’s eye CN V: (-) bicorneal reflex CN VII: shallow right nasolabial fold CN VIII: N/A CN IX, X: good gag CN XI: N/A CN XII: N/A
(+) babinski right, no nuchal rigidity, no clonus
ASSESSMENT: ACS prob NSTEMI KI CAD, HCVD, LVH, AF with SVR-MVR, IV-E
PLAN: Patient was admitted to ICU under the service of Drs. Magbiray/Caole/Torres/Roxas/Estrada. TPR q shift, I and O monitoring, NPO temporarily, IVF TF: D5W 500 cc x KVO. Diagnostics: CBC with PC, CXR-PA, CPK-MB, Na, K, 2D-echo with Doppler, PT,PTT, UA, 12-L ECG q 12, BUN, Crea, Chole, TG, HDL, LDL, FBS, RBS, CT, BT. Therapeutics are the following: Metoprolol 50 mg tab ½ tab q 6; Captopril 25 mg tab TID; ISDN 5 mg tab prn for chest pain; Simvastatin 80 mg tab 1 tab OD; Enoxaparine 0.4 mg/ml SQ BID; Diazepam 5 mg TIV at bedtime on prn basis; Nalbuphine 1 amp TIV prn for severe chest pain; Lactulose 30 cc at bedtime; Omeprazole 40 mg TIV OD. COURSE IN THE WARDS: ST 1 hospital day, patient’s vitals are as follows: 130/80, 80, 20, 36.5. Patient started on low salt, low fat diet. IVF TF: D5W 500 cc x KVO, VSq1 with CR and RR full minute. WOF: occurrence of chest pain. Ref. nd 2 hospital day, patient vital signs are as follows: 110/70, 80, 20, afebrile. Patient was maintained on low salt and low fat diet. IVF TF: D5W 500 cc x KVO. Patient is for 2D-echo with Doppler. WOF: occurrence of chest pain. VSq1 monitoring with CR and RR full minute. Ref.