OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: Narido, Carolina Age/Sex: 78/F Address: 2149 Int 27 Maginhawa St., Malate, Manila Date of Admission: March 18, 2008 Admitting Diagnosis: CHF IV CHD, anterolateral wall ischemia, NSR, E DM Type 2 R/O ACS Residents in charge: Drs. Indon/Esmero/ Clerks in charge: Fabian/Item/Junsay
Hospital No: 1813533
PATIENT DISCHARGE SUMMARY This is a case of a 78 year old female of Malate, Manila who came in due to difficulty of breathing. History of Present Illness Three days PTA, patient had on and off dyspnea and chest pain relieved by rest. These were accompanied by orthopnea, PND and easy fatigability. There was no cough and colds, no fever. No consult was done. Three hours PTA, there was another onset of chest pain at rest with dyspnea which was progressive. Hence consult. Past Medical History DM of 3 years on intermediate insulin s/p ECCE-OMMC-2005 s/p appendectomy 1951 Feb 08-Admitted in Philippine Heart Center due to dyspnea Family History (+) HTN- father Personal Social History Non-smoker non-alcoholic beverage drinker No illicit drug use Review of Systems Gen: no weight loss, no anorexia HEENT: no headache, no dizziness, no gum/nosebleed, no tinnitus, no dysphagia GIT: no abdominal pain, no LBM, no vomiting, no melena GUT: no dysuria, no oliguria, no hematuria Endo: no polyuria, no polyphagia, no polydipsia Neuro: no seizures/no syncope Mus: no myalgia, no arthralgia Hema: no easy bruisibility Physical Examination Gen: conscious, coherent, in distress BP: 130/70 CR: 88 bpm RR:24 cpm Temp: 36.9 °C Skin: no pallor, no cyanosis HEENT: anicteric sclerae, pink palpebral conjunctivae, no alar flaring, no mass, (+) neck vein engorgement, no lympadenopathy C/L: symmetrical chest expansion, no retractions, (+) crackles bibasal Heart: adynamic precordium, PMI at 6ht LICS, AAC, normal rate, regular rhythm, no murmur Abd: flabby, NABS, soft, non tender, no mass Ext: full equal pulses, (+) grade 2 edema ASESSMENT: CHF IV CHD, anterolateral wall ischemia, NSR, E DM Type 2 R/O ACS
Plan: For admission Patient was admitted under the service of Drs. Esmero/Indon. Patient was placed under low salt, low fat diet with SAP and IVF of D5W 500 cc to IV x 10 cc/hr. The following diagnostics were requested: 2D echo Doppler, ECG, BUN, crea, Na, K, Cl, Ca, Mg, CXR-PA, ABG, HBA1C, CBC wih PC, UA, TG, Cholesterol, HDL, LDL, BUA and Troponin I-quantitative. The patient was given the following meds: Furosomide drip (100mg Furosemide in 90cc D5-water) x 10 mg/hr, captopril 25 mg ½ tab TID, Carvedilol 6.25 mg ½ tab BID, Simvastatin 400 mg 1 tab at bedtime, ASA 80 mg 1 tab OD, regular insulin 5 u SQ PRN for CBG greater than or equal to 200 mg/dL and ISDN 5 g 1 tab 5L PRN for chest pain. Patient was put on moderate back rest. Vitals were monitored every hour. CBG before breakfast and 2 hours post prandial. On the 2nd hospital day, patient was started on heparin drip 5800 u + 500 a D5W x120. Furosemide was decreased to 5 ugtts with the same preparation as above. Vital signs were monitored every hour. On the 3rd hospital day, continued on DM diet and heparin drip. Moderate high bed rest was advised. May sit on bed. Strict I and O monitoring. Vital signs were monitored every hour. CR and RR full minute.
Summary of Laboratory Results CBC Normal Values WBC RBC Hgb Hct MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils Blood chemistry: 03-18-08 Glucose BUN Creatinine Cholesterol TG HDL LDL Na K Cl Ca P Hematology Lab Prothrombin Time Activity INR Partial Thromboplastin Clot Retraction Time D-Dimer Urinalysis Color Transparency pH Sp gravity Mucus threads RBC Pus Cells Sugar Albumin Bacteria Epithelial cells Amorphous urates Cast Bacteria 03-19-08 Light Yellow Sl. turbid 5 1.015 Moderate 1-2/hpf 8-10/hpf Negative Negative moderate moderate Hyaline 12/hpf many 3/18/08 15.4 sec 69.9 1.24 31.3 8.6 99.52 4.8-10.8 x 109 /L 4.0-20 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% 03-18-08 8.1 3.47 11.2 34.6 99.5 32.2 32.4 313 70 23.7 4.4 1.9 0