Paulino-ca by dredwardmark

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Paulino, Erlinda Address: 1114 Batanes st., Sampaloc, Mla Date of Admission: January 9, 2008 Admitting Diagnosis: NSTEMI CAD, NSR HCVD, LVH CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2 Residents-in-charge: Drs. Esmero/Gregorio/Sarmiento Clerks-in-charge: Corpuz/Cruz/Cutchon CLINICAL ABSTRACT

Hospital#: 1791376 Age/Sex: 57/F

This is a case of a 50 y/o female from Sampaloc, Manila who came in due to difficulty of breathing. History of Present Illness 14 hours PTA, patient had a sudden onset of dyspnea. There was no chest pain nor palpitation.No meds taken nor consult done. Few hours PTA, due to persistence of the above symptoms prompted consulted at OMMC. Past Medical History (+) HTN maintained on Felodipine and Nifedipine (+) CKD Stage V secondary to DM nephropathy on hemodialysis (-) previous accidents and trauma (-) PTB (-)asthma Family History (-) DM (-) HPN (-) asthma, PTB (-) allergies Personal and Social History Non smoker Non alcoholic beverage drinker No history of illicit drug use Review of Systems General: no fever, no chills, no night sweats, (-) weight loss HEENT: no dizziness, no blurring of vision, no tinnitus, no discharge, (-) headache, no cough, no colds Cardiac: (+) orthopnea (+) easy fatigability (+) PDN Gastrointestinal: (-) nausea, no vomiting, no abdominal pain, no diarrhea, no constipation Genitourinary: no dysuria, no hematuria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no joint pains Physical Examination General: conscious, coherent, in respiratory distress Vital Signs: BP: 200/100mmHg HR: 84bpm RR: 24 cpm Temp: 37 °C HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds th HEART: adynamic precordium, PMI at 6 ICS left anterior axillary line, tachycardic, regular rhythm, no murmur ABDOMEN: flat, normoactive bowel sounds, soft, (-) abdominal pulsation, (-) epigastric tenderness, no splenomegaly, EXTREMITIES: (-) edema,full and equal pulses, no cyanosis, Assessment: NSTEMI CAD, NSR HCVD, LVH CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Paulino, Erlinda Address: 1114 Batanes st., Sampaloc, Mla Date of Admission: January 9, 2008 Admitting Diagnosis: NSTEMI CAD, NSR HCVD, LVH CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2 Residents-in-charge: Drs. Esmero/Gregorio/Sarmiento Clerks-in-charge: Corpuz/Cruz/Cutchon 24-HOUR HISTORY

Hospital#: 1791376 Age/Sex: 57/F

This is a case of a 50 y/o female from Sampaloc, Manila who came in due to difficulty of breathing. History of Present Illness 14 hours PTA, patient had a sudden onset of dyspnea. There was no chest pain nor palpitation.No meds taken nor consult done. Few hours PTA, due to persistence of the above symptoms prompted consulted at OMMC. Past Medical History (+) HTN maintained on Felodipine and Nifedipine (+) CKD Stage V secondary to DM nephropathy on hemodialysis (-) previous accidents and trauma (-) PTB (-)asthma Family History (-) DM (-) HPN (-) asthma, PTB (-) allergies Personal and Social History Non smoker Non alcoholic beverage drinker No history of illicit drug use Review of Systems General: no fever, no chills, no night sweats, (-) weight loss HEENT: no dizziness, no blurring of vision, no tinnitus, no discharge, (-) headache, no cough, no colds Cardiac: (+) orthopnea (+) easy fatigability (+) PDN Gastrointestinal: (-) nausea, no vomiting, no abdominal pain, no diarrhea, no constipation Genitourinary: no dysuria, no hematuria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no joint pains Physical Examination General: conscious, coherent, in respiratory distress Vital Signs: BP: 200/100mmHg HR: 84bpm RR: 24 cpm Temp: 37 °C HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds th HEART: adynamic precordium, PMI at 6 ICS left anterior axillary line, tachycardic, regular rhythm, no murmur ABDOMEN: flat, normoactive bowel sounds, soft, (-) abdominal pulsation, (-) epigastric tenderness, no splenomegaly, EXTREMITIES: (-) edema,full and equal pulses, no cyanosis, Assessment: NSTEMI CAD, NSR HCVD, LVH CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2

Plan:For admission Course in the ward: Upon admission, the patient was placed on NPO except for meds and heplock was maintained. The following diagnostics were done:RBS, ECG, CXR-PA, Trop I, and CBC with PC.O2 support was at 4lpm via nasal cannula . Medications given were: Enoxaprine 0.4 ml SC q12, ASA 80mg, 4 tabs to chew, then 1 tab OD PO, Felodipine 50mg, 1 tab OD PO, Metoprolol 50mg, ½ tab BID PO, Simvastatin 40mg OD PO, ISDN 10mg plus D5water once in a soluset to run at 15microdrops/min, Nalbuphine 5mg PRN, Furosemide 80mg IV q12, Diazepam 5mg q12 , Omeprazole 20mgOD PO while on NPO, FeSO4 1 tab TID PO, and HCO3 TID PO .Vital signs were monitored q4 and CBG monitoring q6.Patient was placed on complete bed rest with no bathroom privilege. Patient was referred to Nephro and the PWI was CKD Stage V secondary to DM Nephropathy with volume overload, DM type 2.Hemodialysis was ordered to be 2x a week. st On the 1 hospital day, the patient was placed on low salt low fat diet and oral feeding was limited to <750cc/day and heplock was maintained. The patient was still for urinalysis with chemistry, ABG, Lipid profile , BUN, Crea, Na, K and Cl. Medications were continued. Vital signs were monitored q4 and CBG monitoring q6.

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Paulino, Erlinda Address: 1114 Batanes st., Sampaloc, Mla Date of Admission: January 9, 2008 Admitting Diagnosis: NSTEMI CAD, NSR HCVD, LVH CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2 Residents-in-charge: Drs. Esmero/Gregorio/Sarmiento Clerks-in-charge: Corpuz/Cruz/Cutchon 48-HOUR HISTORY

Hospital#: 1791376 Age/Sex: 57/F

This is a case of a 50 y/o female from Sampaloc, Manila who came in due to difficulty of breathing. History of Present Illness 14 hours PTA, patient had a sudden onset of dyspnea. There was no chest pain nor palpitation.No meds taken nor consult done. Few hours PTA, due to persistence of the above symptoms prompted consulted at OMMC. Past Medical History (+) HTN maintained on Felodipine and Nifedipine (+) CKD Stage V secondary to DM nephropathy on hemodialysis (-) previous accidents and trauma (-) PTB (-)asthma Family History (-) DM (-) HPN (-) asthma, PTB (-) allergies Personal and Social History Non smoker Non alcoholic beverage drinker No history of illicit drug use Review of Systems General: no fever, no chills, no night sweats, (-) weight loss HEENT: no dizziness, no blurring of vision, no tinnitus, no discharge, (-) headache, no cough, no colds Cardiac: (+) orthopnea (+) easy fatigability (+) PDN Gastrointestinal: (-) nausea, no vomiting, no abdominal pain, no diarrhea, no constipation Genitourinary: no dysuria, no hematuria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no joint pains Physical Examination General: conscious, coherent, in respiratory distress Vital Signs: BP: 200/100mmHg HR: 84bpm RR: 24 cpm Temp: 37 °C HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds th HEART: adynamic precordium, PMI at 6 ICS left anterior axillary line, tachycardic, regular rhythm, no murmur ABDOMEN: flat, normoactive bowel sounds, soft, (-) abdominal pulsation, (-) epigastric tenderness, no splenomegaly, EXTREMITIES: (-) edema,full and equal pulses, no cyanosis,

Assessment: NSTEMI CAD, NSR HCVD, LVH CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2 Plan:For admission Course in the ward: Upon admission, the patient was placed on NPO except for meds and heplock was maintained. The following diagnostics were done:RBS, ECG, CXR-PA, Trop I, and CBC with PC.O2 support was at 4lpm via nasal cannula . Medications given were: Enoxaprine 0.4 ml SC q12, ASA 80mg, 4 tabs to chew, then 1 tab OD PO, Felodipine 50mg, 1 tab OD PO, Metoprolol 50mg, ½ tab BID PO, Simvastatin 40mg OD PO, ISDN 10mg plus D5water once in a soluset to run at 15microdrops/min, Nalbuphine 5mg PRN, Furosemide 80mg IV q12, Diazepam 5mg q12 , Omeprazole 20mgOD PO while on NPO, FeSO4 1 tab TID PO, and HCO3 TID PO .Vital signs were monitored q4 and CBG monitoring q6.Patient was placed on complete bed rest with no bathroom privilege. Patient was referred to Nephro and the PWI was CKD Stage V secondary to DM Nephropathy with volume overload, DM type 2.Hemodialysis was ordered to be 2x a week. st On the 1 hospital day, the patient was placed on low salt low fat diet and oral feeding was limited to <750cc/day and heplock was maintained. The patient was still for urinalysis with chemistry, ABG, Lipid profile , BUN, Crea, Na, K and Cl. Medications were continued. Vital signs were monitored q4 and CBG monitoring q6. nd On the 2 hospital day, the patient was placed on low salt low fat diet and oral feeding was limited to <750cc/day and heplock was maintained. The patient was referred to Cardio and was advised for hemodialysis if not on shock. Vital signs were monitored q4 and CBG monitoring q6.

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Paulino, Erlinda Hospital#: 1791376 Address: 1114 Batanes st., Sampaloc, Mla Age/Sex: 57/F Date of Admission: January 9, 2008 Admitting Diagnosis: NSTEMI CAD, NSR HCVD, LVH CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2 Date of discharge:Feb. 14’08 Discharge Diagnosis: CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2 Residents-in-charge: Drs. Esmero/Gregorio/Sarmiento Clerks-in-charge: Corpuz/Cruz/Cutchon PATIENT’S DISCHARGE SUMMARY This is a case of a 50 y/o female from Sampaloc, Manila who came in due to difficulty of breathing. History of Present Illness 14 hours PTA, patient had a sudden onset of dyspnea. There was no chest pain nor palpitation.No meds taken nor consult done. Few hours PTA, due to persistence of the above symptoms prompted consulted at OMMC. Past Medical History (+) HTN maintained on Felodipine and Nifedipine (+) CKD Stage V secondary to DM nephropathy on hemodialysis (-) previous accidents and trauma (-) PTB (-)asthma Family History (-) DM (-) HPN (-) asthma, PTB (-) allergies Personal and Social History Non smoker Non alcoholic beverage drinker No history of illicit drug use Review of Systems General: no fever, no chills, no night sweats, (-) weight loss HEENT: no dizziness, no blurring of vision, no tinnitus, no discharge, (-) headache, no cough, no colds Cardiac: (+) orthopnea (+) easy fatigability (+) PDN Gastrointestinal: (-) nausea, no vomiting, no abdominal pain, no diarrhea, no constipation Genitourinary: no dysuria, no hematuria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no joint pains Physical Examination General: conscious, coherent, in respiratory distress Vital Signs: BP: 200/100mmHg HR: 84bpm RR: 24 cpm Temp: 37 °C HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds th HEART: adynamic precordium, PMI at 6 ICS left anterior axillary line, tachycardic, regular rhythm, no murmur ABDOMEN: flat, normoactive bowel sounds, soft, (-) abdominal pulsation, (-) epigastric tenderness, no splenomegaly, EXTREMITIES: (-) edema,full and equal pulses, no cyanosis,

Assessment: NSTEMI CAD, NSR HCVD, LVH CKD Stage V secondary to DM nephropathy on hemodialysis DM type 2 Plan:For admission Course in the ward: Upon admission, the patient was placed on NPO except for meds and heplock was maintained. The following diagnostics were done:RBS, ECG, CXR-PA, Trop I, and CBC with PC.O2 support was at 4lpm via nasal cannula . Medications given were: Enoxaprine 0.4 ml SC q12, ASA 80mg, 4 tabs to chew, then 1 tab OD PO, Felodipine 50mg, 1 tab OD PO, Metoprolol 50mg, ½ tab BID PO, Simvastatin 40mg OD PO, ISDN 10mg plus D5water once in a soluset to run at 15microdrops/min, Nalbuphine 5mg PRN, Furosemide 80mg IV q12, Diazepam 5mg q12 , Omeprazole 20mgOD PO while on NPO, FeSO4 1 tab TID PO, and HCO3 TID PO .Vital signs were monitored q4 and CBG monitoring q6.Patient was placed on complete bed rest with no bathroom privilege. Patient was referred to Nephro and the PWI was CKD Stage V secondary to DM Nephropathy with volume overload, DM type 2.Hemodialysis was ordered to be 2x a week. st On the 1 hospital day, the patient was placed on low salt low fat diet and oral feeding was limited to <750cc/day and heplock was maintained. The patient was still for urinalysis with chemistry, ABG, Lipid profile , BUN, Crea, Na, K and Cl. Medications were continued. The patient was placed on moderate to high back rest.Vital signs were monitored q4 and CBG monitoring q6. nd On the 2 hospital day, the patient was placed on low salt low fat diet and oral feeding was limited to <750cc/day and heplock was maintained. The patient was referred to Cardio and was advised for hemodialysis if not on shock. Vital signs were monitored q4 and CBG monitoring q6.By 11pm, the patient was referred to surgery for further evaluation and management of right hand swelling. The patient was placed on moderate to high back rest.The Surgery suggested antibiotics. rd On the 3 hospital day, the patient was placed on low salt low fat diet and oral feeding was limited to <750cc/day and heplock was maintained PT and PTT were requested. Medications were continued. The patient was placed on moderate to high back rest. Vital signs were monitored q1 and CBG monitoring q12 th On the 4 hospital day. the patient was placed on low salt low fat diet and oral feeding was limited to <750cc/day and heplock was maintained. Hemodialysis was done. CBC with PC was repeated. Medications were continued. The patient was placed on moderate to high back rest. Vital signs were monitored q4 and CBG monitoring q6. th On the 5 hospital day, the patient was advised to go home with the following medications: 1. Felodipine 5mg/tab OD 2. ASA 80mg/tab OD 3. Erythropoietin 4000 units SC BID 4. FeSO4 tab TID 5. CaCO3 tab TID 6. NaHCO tab TID 7. Nifedipine 5mg SL of BP>160/100\ 8. Metoprolol 50mg/tab ½ tab BID The patient was advised to come back on Feb.18(Mon) for follow up.

Complete Blood Count Reference Range 5.0 – 10.0 g/L 20.0 – 40.0 % 4.00 – 5.40 g/L 36.0 – 47.0% 120 – 160 g/L 1.0-4.0 2.0-6.0 0.0-0.1 Feb 8 16 17.6 3.14 29.4 8.8 0.4 6.9 0 Feb 13 20.8 9.1 2.19 20.1 7.1 0.7 3.8 0

WBC LYMF RBC HCT HGB EOS Mono BAso

Troponin I(quantitative) 0.15


								
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