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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Santos, Lourders Age/Sex: 84/F Address: 2377 Arellano Ave, Singalong, Manila Date of Admission: March 17, 2008 Admitting Diagnosis: ACS prob UA CAD, 1st Degree AV Block, NSR, IV-E HCVD, LVH DM Type 2 Residents in charge: Drs. Esmero/Indon/Estrada Clerks in charge: Fabian/Item/Junsay

Hospital No: 1809288

PATIENT DISCHARGE SUMMARY This is a case of a 84 year old female from Singalong, Manila who came in due to chest pain. History of Present Illness Patient is a diagnosed case of ACS, CAD lat wall ischemia, HCVD, LVH last March 6, 2008, admitted in this institution x 5 days , discharged improved with the following medications: Metroprolol, Captopril, ASA, ISMN, ISDN with good compliance. Patient was chest pain free at home until at One day PTA, (+) sudden onset of chest pain/chest heaviness radiating to both upper extremities x 20 minutes with associated dyspnea while ate rest. Relief was afforded by ISDN 5 g/tablet. No recurrence of pain. Hence, no consult was done. No PND and no orthopnea. One hour PTA, (+)recurrence of chest heaviness, same character occurring while at rest. Hence consult was done. Past Medical History (+) DM for 3 years-on Metformin OD with good compliance (-) HTN (-) no allergy Family History No hereditofamilial diseases. Personal Social History Non smoker Non alcoholic beverage drinker Review of Systems Gen: no weight loss, no anorexia HEENT: no headache, no dizziness, no epistaxis, no dysphagia Respiratory: (+) occasional cough-non productive, no cold, no dyspnea GIT: no abdominal pain, no diarrhea, no vomiting, no melena GUT: no dysuria, no oliguria, no hematuria Endo: no polyuria, no polyphagia, no polydipsia Hema: no easy bruisability Neuromuscular: no seizures, no myalgia, no arthralgia Physical Examination Gen: conscious, coherent, in distress BP: 130/70 CR: 88 bpm RR:26 cpm Temp: 36.7 °C Skin: no pallor, no cyanosis HEENT: anicteric sclerae, pink palpebral conjunctivae, no alar flaring, no mass, no vein engorgement, no lymphadenopathy C/L: symmetrical chest expansion, no lagging, no retractions, (+) crackles left mid to base Heart: adynamic precordium, normal rate, regular rhythm, PMI at 6th ICS LICS, no murmur Abd: flabby, NABS, soft, nontender, no mass Ext: full and equal pulses, no edema ASESSMENT: ACS prob UA CAD, 1st Degree AV Block, NSR, IV-E HCVD, LVH DM Type 2

Plan: For admission Patient was admitted under the service of Dr. ESmero/Indon/Gutierrez. Consent was secured prior to admission and management. Patient was placed on NPO except meds and in IVF D5Water 500 cc x 12 hours. The following diagnostics were requested: CK=MB, TG, Cholesterol, HDL, LDL, BUA, HBA1C, CBC with PC, ECG, CXR-PA, BUN, Crea, Na, K, Ca, Mg, UA and 2D Echo with Doppler. The following meds wer given: ISDN 5 mg 1 tab as needed for chest pain, Captopril 25 mg ½ tab BID, Metoprolol 50 mg 1 tab BID, Simvastatin 40 mg 1 tab OD at bedtime, Clopidogrel 75 mg 1 tab OD, Enoxaparin 0.4 ml SQ 2x/day, Regular Insulin, 5 u SQ as needed for CBG less than or equal to 250 mg/dl, ranitidine 50 mg to IV every 8 hours, diazepam 5 mg IV as needed for anxiety and nalbuphine 5 mg to IV as needed for severe pain. Patient was advised on moderate back rest. Vitals were monitored every hour and CBG every every 6 hours. Patient was placed on complete bed rest without bathroom privilege. Patient was hooked to cardiac monitor and pulse oximeter. On the 2nd hospital day, BP = 150/70, HR= 70, RR=20, temp = 36.7, (+) bibasal crackles, adynamic precordium, (-) murmurs, soft s1, (-) S3 and S4. Patient was given O2 support. Patient as put on PNSS 1L x 24 then shift to heplock. Patient was advised some soft diet with aspiration precaution. HgBA1C, HDL, LDL, TG, Cholesterol, BUA and 2D echo with Doppler were deferred. Patient was given the following medications: ASA 80 mg/tablet OD, Captopril 25 mg/tablet, ½ tablet BID PO. Simvastatin 20 mg OD at bedtime. Metformin 500 mg TID PO before meals, Enoxaparin 0.6 ml

SQ BID. ISDN 10 mg 1 tab SQ TID PO with BP precautions. Clopidogrel and Ranitidine were discontinued. Patient could sit onbed. Vitals were monitored every hour. On the 3rd hospital day, BP=140/70, RR=20, CR=86 and temp=37.8. Patient was maintained on heplock. Medications were continued. Vitals were monitored every hour. Omeprazole 40 mg was given for epigastric pain. On the 4th hospital day, patient was continued on DM diet, maintained on heplock and continued with meds. Patient was places on moderate high back rest and could dangle feet over side of bed. Strict I and O monitoring was done. Vitals monitored every hour, CR and RR were done full minute and CBG was done before meal and post prandial. On the 5th hospital day, patient had no chest pain, no fever, BP 100/60, CR 72, RR 19, temp: afebrile. Patient had may go home orders. Patient was recommended the following drugs: ASA 80mg OD, Captopril 25mg ½ tab Bid, Metoprolol 50mg ½ tab Bid, Simvastatin 40 mg OD, ISDN 5mg for chest pain episodes, metformin 500mg Tid. IM OPD follow-up this coming Monday.

Laboratory Results Summary CBC Normal Values WBC RBC Hgb Hct MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils CK-MB (3/18/08): 2.9 U/L Blood chemistry: 03-17-08 Glucose BUN Creatinine Cholesterol Albumin TG HDL LDL Na K Cl Ca P Mg 4.8-10.8 x 10 /L 4.0-20 x 10
12 9

3-17-08 11.2 3.26 10.5 31.1 95.5 32.2 33.7 211 69.8 24.2 4.2 1.2 0.6

/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%

98

143 4.1 107 2.13 0.69


								
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