OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: Shirley Fernandez Address: Baseco, Port Area Manila Date of Admission: March 31, 2008 Admitting Diagnosis: Community Acquired Pneumonia, Moderate Risk Abnormal Uterine Bleeding r/o EM Pathology Residents-in-charge: Drs. Gutierrez/Dimaandal/Areja Clerks-in-charge: Liwag/Lopez
Hospital #:1817790 Age/Sex: 42/F
CLINICAL ABSTRACT This is a case of a 42 year old female who came in due to difficulty of breathing. Patient was diagnosed with Rheumatic heart disease when she was 14 years old at a Bacolod hospital and was given digoxin and captopril with good compliance. History of Present Illness 1 month prior to admission, the patient had difficulty of breathing associated with easy fatiguability and orthopnea. There was no paroxysmal nocturnal dyspnea or chest pain. Patient also had vaginal bleeding of 3 pads/day. She consulted a private physician who diagnosed her with dysfunctional uterine bleeding. She was given Provera. 1 week prior to admission, symptoms stated above persisted. The patient also had cough with production of yellowish sputum and undocumented fever. No consult was done. A few hours prior to admission, patient experienced increasing severity of difficulty of breathing, hence she sought consult at the OMMC where she was subsequently admitted. Past Medical History: The patient denies any history of diabetes mellitus, hypertension or allergy to food or drugs. Patient has liver disease in 1990. OB history: Patient is G4P3 (3013). She had her menarche at 19 years old, regular menstruation, 3 days duration, interval 27 days with 4 napkins per day. Her first coitus was at 24 years old. She had 3 sexual partners. She does not take any OCPs, but uses only condom. Denies of having STD, dyspareunia, post-coital bleeding. Her Last Menstrual Period July 14, 2008. She has vaginal bleeding since December 2007. G1 1985 Male term NSVD Fabella Hospital G2 1988 Male term NSVD Fabella Hospital G3 1990 Male term NSVD Fabella Hospital G4 2001 Male abortion Fabella Hospital Family History: (+) Rheumatic heart disease – maternal side The patient denies existence of other heredofamilial disease. Personal and Social History: Smoker for 10 pack years; stopped in 1995. Alcoholic beverage drinker, consumes 2 bottles of beer 3 times a week for 10 years; stopped in 1990. Review of Systems: General: weight loss of 50% in 1990, with loss of appetite. HEENT: Gastrointestinal: no abdominal pain, no change in bowel movement Genitourinary: no dysuria, no hematuria Endocrine: no polydipsia, no polyphagia, no polyuria Neurologic: no headache, no loss of consciousness, no seizure Physical examination: General: conscious, coherent, in cardiorespiratory distress BP – 150/80 CR – 85, regular rhythm RR – 24 cycles/minute T – 37 HEENT: anicteric sclera, pink palpebral conjunctiva, no naso-auaral discharge, no tonsilo-pharyngeal congestion, no palpable cervical lymph nodes, neck vein distension C/L: symmetrical chest expansion, (+) retractions, (+) crackles on both lung fields th Cardiovascular: dynamic precordium, Apex beat at 6 LICS MCL, distinct S1 and S2. Abdomen: flat, NABS, soft, non tender Extremity: no cyanosis, no edema, pulses full Assessment: Community Acquired Pneumonia, Moderate Risk CAD, AF w/ MVR, E RHD, Biventricular Enlargement AUB r/o EM pathology
Plan:
Admit