mario abstract - DOC by dredwardmark



Name: FRANCISCO, MARIO Age/Sex: 46/m Address: Sta.Ana Manila Date of admission: July 18,2007 Admitting Diagnosis: Acute coronary syndrome prob NSTEM K IV CAD t/c Bilateral Cardiomyopathy Cardiomegaly, PVC, E t/c CPC of the liver vs CLD PTB IV Residents in charge: Dr.Magbiray/Gonzales/Filio/Indon Intern-in-Chage: Maganda Clerk-in-Charge: Navarro/Ponelas/ Reyes

Hospital #: 1711175

Clinical Abstract
This is a case of a 46 year-old male who came in due to difficulty of breathing History of Present Illness 1 month PTA, week PTC, patient had easy fatigability of 1 block , orthopnea of 2 pillows, paroxysmal nocturnal dyapnea , bipedal edema, no cough nor colds. Consult was done at IM OPD OMMC, patient was given Furosemide & Spirinolactone providing slight relief of edema. 2 weeks PTA, still with the persistence of the above conditions, ff up check up was done. Patient medicated with Furosemide & Spirinolactone which the patient took , providing no relief of bilateral edema which progressed up to the leg. 1 day PTA, still with persistence of above conditions, edema progressed up to the abdomen, associated with chest pain, severity of 7/10, radiating to the back. Persistence prompted consult hence the admission. Family History 1993- CAD, Cardiomegaly, no meds no consult + HPN- HBP= 140/90 UBP= 130/80 no maintenance Personal and Social History >20 years shabu and marijuana user Non alcoholic beverage drinker 10 pack years smoking hx Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Gastrointestinal: (-) abdominal pain, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (+) polyuria, (+) polyphagia, (+) polydipsia Muscular: - general body weakness Physical Examination: conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 120/80 HR: 74 RR: 24 Temp: 37.2 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (+) distended neckm veins CHEST AND LUNGS: symmetrical chest expansion, - retraction, (+) diffuse crakles , (-) wheezes HEART: adynamic precordium,PMI 6th ICS AAL , NRRR, no murmur ABDOMEN: globular, normoactive bowel sound, soft, non-tender EXTREMITIES: + grade4 bipedal edema, full equal pulses Assessment:

Acute coronary syndrome prob NSTEM K IV CAD t/c Bilateral Cardiomyopathy Cardiomegaly, PVC, E t/c CPC of the liver vs CLD PTB IV
PLAN: For admission

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