Perez_ Teodora - DOC

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					Ospital ng Maynila Medical Center Department of Internal Medicine

Name: Perez, Teodora Age/Sex: 71/f Address: Sta. Mesa, Manila Date of Admission: July 3, 2007 Admitting Diagnosis: Cardiovascular disease probably hemorrhagic, probably cerebellar CAD, HCVD, LVH, NSR, II-B Residents in charge: Drs. Gregorio/Filio/Indon Clerk-in-charge: Villanueva/Villarama/Ybanez

Hospital No: 1445201

Date of discharge: Final Diagnosis:

Patient’s Discharge Summary General Data This is a case of a 71 year old female from Sta. Mesa, Manila, who came in due to dizziness. History of Present Illness 5 fooddays prior to admission, the patient experienced dizziness upon movement of head. The patient also felt temporal headache, non-radiating thereby relieved spontaneously. She also experienced vomiting of the previously digested food. No loss of consciousness, no blurring of vision, and no fever were noticed. No consult was done and no medications taken. 3 days prior to admission, there was persistence of the said symptoms accompanied by fever, temperature undocumented. Still no consult was done. Few hours prior to admission, the symptoms still persisted and the patient sought consult at Lourdes Hospital where she was diagnosed with UTI and BPPV vs. CVD. Patient was allegedly sent home. Persistence of the symptoms prompted consult and the subsequent admission at our institution. Past Medical History (+) s/p AMI April 2006 admitted at OMMC with medications: ISMN 30 mg BID, Imidapril 10 mg OD, ASA 80 mg OD (+) HPN x 6 years HBP: 200/100 UBP: 140/80 (-) DM (-) BA Family History (+) HPN – paternal side no DM, no BA Personal and Social History Non-smoker Non alcoholic beverage drinker Review of Systems General: noweight loss, no anorexia, no chills, no night sweats HEENT: no tinnitus, no ear discharge, no changes in hearing, no sore throat Chest and Lungs: no cough, no colds, no hemoptysis Cardiac: no palpitations, (+) occasional chest pain, (+) easy fatiguability, no orthopnea, no PND Genitourinary: no hematuria, no dysuria, no oliguria Endocrine: no polyphagia, no polydipsia, no polyuria Hematologic: no easy bruisability, no easy bruisability Neurologic: no seizure, no changes in sensorium Physical Examination: On admission patient was conscious, coherent, afebrile and not in cardio-respiratory distress Vital Signs: BP 140/80 HR: 88 RR:20 Temp: 36.7oC HEENT: pink palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, supple neck, no cervical lymphadenopathy, no neck vein distention CHEST AND LUNGS: symmetrical chest expansion, no retractions, no lagging, clear breath sounds HEART: adynamic precordium, PMI at 6th ICS LAAL, normal rate regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, nontender EXTREMITIES: grossly normal extremities, no cyanosis, no edema, (+) joint tenderness on the knee NEURO: conscious, coherent, oriented to three spheres

Cranial nerve exam: I – can smell II – visual fields intact III, IV, VI – EOM’s intact V – (+) bicorneal reflex VII – no facial asymmetry VIII – can hear IX, X – good gag XI – can shrug shoulders XII – tongue midline on protrusion



Deep tendon reflexes

Can do finger-to-nose test but with difficulty Unable to do heel-to-shin test due to knee pain on movement (+) dysdiadokinesia (-) Babinski (-) nuchal rigidity ASSESSMENT: CVD prob. hemorrhage, prob. cerebellar CAD, HCVD, LVH, NSR, II-B UTI

COURSE IN THE WARDS: The patient was admitted into the Infirmary ward under the service of Dr. delos Reyes-Gonzales/Dr. Filio/Dr. Indon. Patient was hooked to IVF of PNSS and put on low fat, low salt diet. Laboratory and diagnostic exams requested were CBC with PC, urinalysis, CXR-PA, cranial CT scan, and serum BUN, creatinine, sodium, potassium, HDL, LDL, TG, cholesterol, and BUA. Medications given were: Citicoline 500 mg/amp TIV q8, Captopril 25 mg/tab 1 tab TID PO, Clonidine 75 mg tab SL for BP≥160/100, ISMN 30 mg BID, ISDN 5 mg SL for chest pain, Metoprolol 50 mg/tab ½ tab BID, Mannitol 100 q8 TIV, Cinnarazine 75 mg tab OD, and Metoclopramide q8 for vomiting. Patient’s vital signs and neurologic status were monitored hourly and CBG monitored AC/HS. Patient was watched closely for fever and progression of neurologic deficits. On the first hospital day, patient still had dizziness but was not in distress. The patient’s vital signs were at 130/90 BP, HR 84, RR 20, and temp 36.9 °C. Patient was started on Clopidogrel 75 mg/tab 1 tab OD, Aspirin 80 mg tab OD after lunch, ISMN 60 mg ½ tab BID, and ISDN 5 mg tab SL PRN for chest pain. Other medications were continued. On the second hospital day, patient still had dizziness and had nausea with no vomiting, no headache, and no seizures. Mannitol was tapered to 100 mg TIV q 12 for 2 doses then q4. Other medications were continued. On the third hospital day, patient was conscious, coherent, afebrile, and with no subjective complaints. Patient was sent home with the following home medications: Citicoline 500 mg 1 tab BID for 6 weeks, Nicorandil 10 mg ½ tab BID, ISDN 5 mg/tab 1 tab SL PRN for chest pain, ASA 80 mg/tab 1 tab OD after lunch, Clopidogrel 75 mg 1 tab OD, Candesartan 16 mg + HCTZ 1 tab OD after breakfast, Captopril 25 mg/ tab SL PRN for BP≥160/100, Ofloxacin 400 mg/tab BID to complete 4 days, Metoprolol 50 mg/tab 1 tab BID, and Simvastatin 20mg tab before bedtime. 2D-echo with Doppler was requested on an OPD basis. Patient was advised to follow-up at the IM-OPD on July 10, Tuesday at 1pm.

Summary of Laboratory and Diagnostic exams: Complete Blood Count Normal Values 7/3/07 WBC 4.8-10.8 x 109 /L 16.0 RBC 4.0-6.20 x 1012 4.1 /L Hgb 12-16g/dl 12.2 Hct 37-47 % 36.7 MCV 80-90 fL 90.1 MCH 27-31 30.1 MCHC 32-36 33 Platelet 150-400 x 192 10^9/L Neutrophils 55-57 96.5 Lymphocytes 20-30% 1.3 Monocytes 0-7% 1.8 Eosinophils 0-3% 0.4 Basophils 0-1% 0 Hypochromia: (+); Anisocytosis: (+++); Poikilocytosis (+); TG (-)

Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphus Urates Pus Cells Erythrocytes Albumin Sugar Sp gravity pH bacteria 7/3/07 Yellow Clear Occasional Many few 1-2 1-3 Trace Negative 1.030 6.0

Blood Chemistry Normal Values BUN 2.5 - 7.10 mmol/L Creatinine 53 – 115 umol/L Glucose 3.9-6.4 mmol/L Uric acid 202-416.5 (male) 142.8-339.2 (female) Sodium 140-148 mmol/L Potassium 3.6 – 5.2 Chloride 100-108 mmol/L Triglycerides 0.34-1.70 HDL 0.91-1.56 Cholesterol 5.20-6.20 LDL 1.10-3.80 Alk phos 35 – 120 U/L Total protein 66-87 g/L Albumin 34-48 g/L S. Globulin 20-38 g/L

7/3/07 12.5 NA 5.0 454.33

1.74 0.80 3.3 1.71

CT scan July 3, 2007 Findings: 1. Hypodense non-enhacing focus in left external capsule 2. Ventricles are not dilated 3. No shift of midline structures 4. Posterior fossa unremarkable 5. Satisfactory opacification of the major intracerebral vessels Impression: Cerebral infarction, left external capsule

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