cpc4case_lal by dredwardmark


									GENERAL DATA This is the case of J. N., 39 years old male, Filipino, Roman Catholic, born on June 19, 1961, presently residing at 3351 Buenos Aires St., Sta. Mesa, Manila, admitted Rizal Medical Center on February 21, 2001 CHIEF COMPLAINT Difficulty in breathing HISTORY OF PRESENT ILLNESS The present condition started 13 months prior to consult, when the patient began to experience dyspnea, easy fatigability and edema of the lower extremities. Consult was done with a private physician and was prescribed Vastarel for 5 months with poor compliance. Two weeks prior to admission, he again experienced dyspnea with on and off cough, chest pain and night chills. There was progression of edema. Consult was done at Jose Reyes Memorial Medical Center. Chest X-ray and ECG was requested. He was prescribed with Furosemide 20mg OD, ISDN 5mg PRN, ASA 80mg OD, Imdur 60mg ½ tab OD, Captopril 25mg ½ OD and Myrin P 4 tablets OD. 14 hours prior to admission, there was dyspnea upon exerting a few steps, with comcomitant crampy epigastric pain. The patient consulted a private hospital and was subsequently referred to this institution. PAST MEDICAL HISTORY The patient acquired Hepatitis A infection in 1992 FAMILY HISTORY Mother has cardiac disease. No diabetes mellitus PERSONAL SOCIAL HISTORY Alcoholic drinker since 13 years old, 5x a week, 2 bottles of gin, 7 bottles of beer. Non smoker PHYSICAL EXAMINATION Gen. Survey: Patient is conscious, coherent, ambulatory, in mild respiratory distress Vital Signs: BP-90/60 HR-108bpm RR- 32cpm Skin: Fair skin turgor HEENT: pink palpebral conjunctivae, icteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, (+) cervical lymphadenopathy Chest & Lungs: symmetrical chest expansion, slight intercostals retractions, no rales, no wheezes, decreased breath sounds R mid to basal field, increased vocal fremitus R upper field Heart: adynamic precordium, tachycardic, regular rhythm, no murmurs Abdomen: flabby, soft, non-tender, no hepatomegaly Extremities: no gross deformities, Grade 3 pitting edema

COURSE IN THE WARD Upon admission, patient was venoclysed with D5NSS. Ecg, CXR and laboratory examinations were requested . He was given Aspirin, Carvedilol, Spirinolactone, Digoxin, Furosemide, and ISDN. Vital signs and fluid input/output were monitored. Patient was maintained on high back rest. Oxygen inhalation at 1 lpm via nasal cannula was given. CXR revealed cardiomegaly, pulmonary congestion, and pulmonary tuberculosis. He was scheduled for UTZ of the upper abdomen and 2D-echo. On the 2 nd hospital day, vital signs were stable, PE revealed crackles in the left lower lung field. ECG revealed R axis deviation, R ventricular hypertrophy, ischemia of the apicoseptal wall. ISDN was discontinued. On the third hospital day, vital signs remained stable. Furosemide was increased with the fluid intake limited to 1.5 L per day. All medications were continued. On the fourth hospital day, vital signs remained stable. The patient had harsh breath sounds and still had bipedal edema. Fundoscopy findings were normal. On the 5th hospital day, the BP was 70/40. The following medications were put on hold: Furosemide, Carvedilol, Spironolactone, and Imidapril. Dopamine drip was ordered but was not started. On the 6th hospital day, vital signs became stable. The patient had leg pains, and was prescribed Celecoxib. On the 7th hospital day, the vital signs remained stable. The patient still had harsh breath sounds. The patient’s diuretic was again started and Celecoxib discontinued. On the 8th hospital day, the patient had clear breath sounds but there was pain and swelling on a previous IV site. Antibiotic was started and repeat CXR was scheduled. On the 9th hospital day, the vital signs remained stable. The patient’s 2D-echo was yet to be done. Management was continued. On the 10th hospital day, at 8:30 am, the patient had mild difficulty in breathing but there was clear breath sounds and decrease bipedal edema. BP=100/60, HR=108, RR=20. Oral diuretics was increased. The patient was due for 2D-echo at 10am. At 9:45am, there was difficulty in breathing, BP was palpatory, and cold clammy extremities. All hypertensive drugs were put on hold. CK-MB and CPK total and ABG were requested. Dopamine drip was started. The patient was transferred to ICU and hooked to O2 inhalation at 3-4lpm.At around 3 pm, the patient went into cardiopulmonary arrest. The patient then expired despite resuscitative measures.

LABORATORY RESULTS CBC Hgb Hct Plt WBC Neut Lymp 2/21 146 0.44 100 12.1 0.80 0.20 2/26 123 0.38 adeq 17.1 0.90 0.10 3/1 142 0.44 adeq 14.4 0.86 0.13

Coagulation Studies Patient Protime Control % Activity INR Blood Chemistry 2/20 Glucose BUN Crea Trigly Chole HDL Na K Cl TP AST ALT ALP TB DB IB Urinalysis Alb Sugar Ketones Bili WBC RBC MT 5.27 175.07

17 (10-14secs) 13 76.47 (75-100) 1.22

2/21 8.3 76

2/22 3.78



0.81 2.8 0.4 131 4.63 97.53 64.0 45.7 33.7 36.5 17.3 19.2 2/21 +1 neg neg neg 4-6 5-8 few 3/1 +3 neg neg +1 2-3 20-25 +1 48.6 98.4(112) 54.2 42

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