Docstoc

estrada_ca

Document Sample
estrada_ca Powered By Docstoc
					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Estrada, Encarnacion Age/Sex: 82/F Address: 2970 F. Manolo Punta Sta.Ana Manila Date of admission: August 29, 2007 Assessment: AMI Killip II CAD, HCVD, Septal wall MI, NSR, E T/C pulmonary vs mediastinal mass Residents in charge: Drs.Dalanon/Gutierrez/Gregorio CIC: Palay/Rentillo/Roxas Clinical Abstract

Hospital #: 1727966

This is a case of an 82 year-old female who came in to IM-ER due to difficulty of breathing History of Present Illness Patient has been having on and off dyspnea in the past week ws and symptoms. No consult done. No medications taken. Few hrs PTA, she had increased severity of dyspnea. No chest pain, couh, orthopnea, PND, fever noted. No meds taken. Persistence of the condition prompted consult hence the admission. Past Medical History (+) HPN on Metoprolol 50mg PRN (-)DM, BA Family History Patient denied heredofamilial disease. Personal and Social History Non smoker, non alcoholic beverage drinker Review of Systems General: (-)weight loss, (-) anorexia HEENT: no blurring of vision, no tinnitus GIT: No abdominal pain, no change in bowel movement GUT: no dysuria, no hematuria, no oliguria M/S: no joint pain. Hematologic: no easy brusability Neurologic: no seizure, no loss of consciousness Physical Examination: Conscious, coherent in respiratory distress Vital Signs: BP: 160/80 HR: 84 RR:18 Temp: 35.8oC HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no palpable cervical lymphadenopathies, no neck mass, (+) NVE CHEST AND LUNGS: symmetrical chest expansion, (+) crackles right lung field HEART: adynamic precordium, AB at 5th LICS MCL, no murmur ABDOMEN: flabby, NABS, soft, nontender EXTREMITIES: grossly normal, full equal pulses, no edema, no cyanosis Assessment: AMI Killip II CAD, HCVD, Septal wall MI, NSR, E T/C pulmonary vs mediastinal mass Course in the Ward: Upon admission, Patient was placed on NPO except meds. She was hooked to IVF: D5W 500mL x KVO. Diagnostic procedures requested were 12-lead ECG q6, CBC c PC, urinalysis, CXR- PA, Troponin 1 quanti, FBS, BUN, Crea, Na, K, HDL, LDL, TG, cholesterol, BUA, Ca, Mg PO4, PT, PTT, KUB UTZ, ABG’s,Hb A1C. Therapeutics given were: 1. ASA 80mg/tab, 4 tabs chewed and swallowed then 1nta OD 2. Clopidogrel 75mg/ tab OD 3. Metoprolol 50 mg/tab ½ tab BID 4. Captopril 25mg/tab OD 5. ISDN 5 mg/ tab TID 6. Simvastatin 20mg/tab OD at HS 7. Diazepam 10 mg/2mL Amp ½ amp IV OD at HS 8. Nalbuphine 10mg/mL amp, ½ amp PRN IV for severe chest pain 9. Heparin 3600 u IV Bolus, then heparin 8640 u Heparin in D5W 500 mL to run for 12 hours 10. Regular Insulin 5 u SL PRN for CBG≥250mg/dL 11. Furosemide drip: D5W 100cc + 80 mg at 10 cc/hr

On the 2nd HD, vital signs were as follows: BP 100/60 CR 55 RR 20 Temp36.5°C. NGT was inserted and OF feeding was started Furosemide drip to consume. She was scheduled for KUB utz and CXR left lateral upright revealing aortic aneurysm, Hilar mass, Pneumonia, Several etallic objects noted on soft tissues. Chest CT scan was also requested. Captopril, Metoprolol, ISDN was placed on hold temporarily. Other medications were continued. On the 3rd – 5th HD, vital signs were as follows: BP range was 80-150/60-90 afebrile with normal cardiac and respiratory rate. CVP hydration was ordered. Dopamine increased to 30cchr then eventually discontinued. IVF PNSS 1L hooked to run at 100cc/hr. blood CS and 2D echo with Doppler was also requested. Cefuroxime 750mg/vial 1 vial q8 and azithromycin 2 g PO single dose also given. Laboratory Results: X-RAY CHEST Osteoarthritis Pleural effusion bilateral Cardiomegaly with PUI edema AA Complete Blood Count Normal Values WBC 4.8-10.8 x 109 /L RBC 4.0-6.20 x 1012 /L Hgb 12-16g/dl Hct 37-47 % MCV 80-90 fL MCH 27-31 MCHC 32-36 Platelet 150-400 x 10^9/L Neutrophils 55-57 Lymphocytes 20-30% Monocytes 0-7% Eosinophils 0-3% Basophils 0-1% aPTT – Aug 29 – 31.4 sec Aug 30 – 36.6 sec Blood Chemistry Result BUN Creatinine Sodium Potassium FBS HDL LDL VLDL HDL RATIO TG Cholesterol BUA Calcium Magnesium CPK-MB Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphous Urates Pus Cells Erythrocytes Cast Albumin Sugar SG pH Amorphous Phosphate Bacteria Calcium Oxalate Aug 29 Yellow Slightly Turbid Few Few Few 0-1 Many 5.87 92.19 146.6 3.87 5.2 1.54 5

Aug 29 7 3.8 12 35.5 93.6 31.5 34 192 55.6 35.3 5.6 2.6 0.9

0.77 6.25 432.64

9


				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:16
posted:7/4/2009
language:Latin
pages:2