OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: Marantal, Crizalito Age/Sex: 20/M Address: 4887 Int. B Guadalcanal Sta. Mesa, Manila Date of admission: July 28, 2007 Admitting Diagnosis: CAP moderate risk Residents in charge: Drs. Torres/ Roxas/ Estrada Clerks-in-Charge: Navarro/Ponelas/Reyes
Hospital #: 1715471
48-H HISTORY Patient is a diagnosed case of COPD maintained on Salbutamol + Ipratropium nebule, Doxofylline, tiotropium, Salmeterol + Fluticasone, with poor compliance. History of Present Illness Two weeks prior to admission, patient had cough productive of whitish phlegm. No DOB, no fever, no chest pain, no vomiting. No medications, no consult was done. One week prior to admission, there was persistence of cough, with whitish to yellowish phlegm. He has fever, undocumented, no chest pain, no abdominal pain. He had consult at a private physician, given Co-Amoxiclav tab affording temporary relief. Five days prior to admission, there is still persistence of the above symptoms; have difficulty of breathing with cough with greenish phlegm. Self medicated with salbutamol and ipratropium affording temporary relief. Two days prior to admission, still persistence of above condition, still no consult. Few hours prior to admission, persistence prompted consult, hence the admission. Past Medical History No previous operations, no hypertension, no diabetes mellitus, no bronchial asthma, no TB. Family History Patient denies any heredofamilial disease. Personal and Social History Previous smoker with 60 pack years; Occasional alcoholic beverage drinker Review of Systems General: no weight loss HEENT: no blurring of vision, no tinnitus Respiratory: no hemoptysis Cardiac: no palpitation, no orthopnea Urinary: no dysuria Endocrine: No polyphagia, no polyuria, no polydipsia Rheuma: No joint pains Physical Examination: Conscious, coherent, not in distress Vital Signs: BP: 110/70 HR: 98 RR: 32 Temp: 36.8C HEENT: Anicteric sclera, pink palpebral conjunctivae, no nasoaural discharge, no cervical lymphadenopathies, no tonsillopharyngeal congestion CHEST AND LUNGS: symmetrical chest expansion, (+) supraclavicular retraction, (+) crackles BLF th HEART: adynamic precordium, PMI at 6 ICS LMCL ABDOMEN: flabby, NABS, soft, nontender. EXTREMITIES: grossly normal, with full and equal pulses, no edema Assessment: Pneumonia Community Acquired, Moderate Risk COPD in Acute exacerbation PLAN: For admission Course in the wards: Upon admission, he was placed under the service of Drs. Payumo, Aguila, Receno, Dimaandal. With the consent of the patient, the following orders were given: TPR q shift, I and O monitoring, regular diet with strict aspiration precaution, IVF FF: D5W 500cc x KVO, (diagnostics) CXR PA, CBC with pc, sputum GS/CS, Blood CS x 2 sites, 12L ECG, UA, Sputum AFB, BUN, crea. Therapeutics: 1. Co-amoxiclav 1.2g TIV BID, 2. Clarithromycin 500mg tab, BID PO, 3. Aminophylline drip: 500cc D5W 2 amps APL x 20 ugtts/min, 4. Tiotropium cap inhaled via handihaler, 5. Salbutamol +
Ipratropium nebulization every 6 hours, 6. Erdosteine 300mg tab TID, 7. Hydrocortisone 100mg IV q6hours. He was maintained on oxygen support via nasal canula at 41ppm. Monitored every hour, with I and O monitoring. On the first day of admission, BP 110/80, CR 120bpm, RR 30 cpm, T 37.5C, (+) wheezes BLF, (+) cough productive of yellowish phlegm. Diet was regular, with IVF of D5W 500ml + 2amp Aminophylline at 20ugtts. Medications were secured and continued. Monitored hourly. On the second hospital day, BP 120/70, PR 81, RR 20, Temp. 37. Regular diet continued, for reinsertion of IV line, PNSS 1L + 40 meq to run for 8 hours. Labs requested are Blood CS, sputum GS/CS, ABG, Serum Cl, Spot urine potassium, and repeat cbc and pc. Official CXR result for follow up. Medications continued except co-amoxiclav which was shifted to oral 625mg TID PO. B Citrate 1 tab TID PO was given, and dextromethorpan syrup 1tbsp BID PO. Mefenamic acid was discontinued. Salbutamol was shifted PRN.