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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Perecho, Gualberto Address: 774 A. Sevilla St. Binondo, Manila Date of Admission: April 11, 2008 Admitting Diagnosis: CHF III DM type 2 Dilated Cardiomyopathy Physicians-in-charge: Drs. Receno/Roxas/Indon/Cruz Clerks-in-charge: Liwag/Lopez Clinical Abstract

Hospital#: 1821864 Age/Sex: 54/M

This is a case of a 54 y/o male from , Manila who came to OMMC due to swelling of both lower extremity. Patient is a diagnosed case of Dilated Cardiomyopathy, in a health center, 2 months ago, and is maintained on Lanotin 0.25 mg OD with poor compliance. History of Present Illness 2 months prior to admission, patient had bipedal edema, with palpitations, paro xysmal nocturnal dyspnea, 2-3 pillow orthopnea, with occasional cough. Patient was given Furosemide in a health center. Patient was initially with good compliance with disappeara nce of edema early in the morning. Patient however reported easy fatigability. Patient had no chest pain. 1 month prior to admission, patient reported of poor compliance to Furosemide with progression of edema up to bilateral legs then reaching both thighs. No consult was done. 2 weeks prior to admission, patient reported edema involving the scrotal area gradually enlarging still with the previously mentioned signs and symptoms. Patient still did not seek consult. 1 week prior to admission, patient had difficulty ambulating due to enlarging lower extremities. Thus, patient sought consult at OMMC. Past Medical History (+) TB – previously treated for 6 months. No Diabetes mellitus No hypertension No bronchial asthma No allergies No previous operation No previous hospitalization Family History (+) Diabetes mellitus – brother (+) CAD – paternal and maternal side Personal and Social History 160 pack years smoker Previous heavy alcoholic beer drinker, 2 bottles gin bulag/day 4-5x per week Review of Systems General: (+) weight loss, (+) loss of appetite HEENT: no dizziness, no headache, no tinnitus, no dizziness, no dysphagia Respiratory: no colds, (+) dyspnea Gastrointestinal: no abdominal pain, no constipation, no melena Genitourinary: no dysuria, no hematuria, no oliguria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Neurology: no seizure Musculoskeletal: no myalgia, no arthralgia Physical Examination General: conscious, coherent, not in cardio-respiratory distress Vital Signs: BP: 100/70 mmHg HR: 90 bpm RR: 27 cpm Temp: 37.4°C Skin: No pallor, no cyanosis HEENT: anicteric sclera, pink palpebral conjunctivae, no alar flaring, no mass, no cervical lymphadenopathies, (+) neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, equal breath sound on both lungs HEART: adynamic precordium, PMI at 6th ICS left midclavicular line, normal regular rate rhythm, no murmur ABDOMEN: globular, soft, normal abdominal bowel sounds, non tender, normoactive bowel sounds EXTREMITIES: (+) grade III edema Assessment: CHF III Dilated Cardiomyopathy, NSR III-C DM Type 2 Plan: for ADMISSION Laboratory Requested: CBC with PC ECG CXR-PA, lateral upright

Medications:

2D echo with doppler UA BUN, Crea, Na, K, Cl HgbA1C TG, TC, HDL, LDL, BUA Serum albumin AST, ALT Spirinolactone 25 mg/tab BID Captorpil 25 mg ¼ tab TID Regular Insulin 5 'u' SQ PRN if CBG ≥ 250 mg/dL Intermediate Insulin 12 'u' in AM; 6 'u' in PM Lanoxin 0.25 mg 1 tab OD ISDN 5 mg 1 tab TID PO


				
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posted:7/4/2009
language:English
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