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valdez ca OPHTHA REFERAL

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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Valdez, Ramon Address: 1217 Meding St. Singalong, Manila Age/Sex: 54M Date of Admission: April 19, 2008 Admitting Diagnosis: Secondary Pneumothorax PTB III T/C COPD S/P CTT Insertion (R) Physicians-in-charge: Drs. Receno/Roxas/Indon/Cruz Clerks-in-charge: Kalalo/Lingao Clinical Abstract This is a case of a 54 y/o male from Manila who came to OMMC due to difficulty of breathing.

Hospital#: 1825402

History of Present Illness Two months PTA, patient was diagnosed with PTB and is on anti Koch’s treatment at a health center for 2 months now. 1 week PTA, patient complained of sudden onset dyspnea. Patient denied of having cough, fever or chest pain. No consult was done or any medications were taken. Six hours PTA, severity of dyspnea increased prompting consult at the OMMC-ER where he was subsequently. Past Medical History No Diabetes mellitus No hypertension No bronchial asthma No allergies No previous operation No previous hospitalization Family History Denies any heredofamilial diseases Personal and Social History 32-pack year smoker Non alcoholic beverage drinker Review of Systems General: (+) weight loss, (+) loss of appetite HEENT: no dizziness, no headache, no tinnitus, no dizziness, no dysphagia Respiratory: no cough, no colds Gastrointestinal: no abdominal pain, no constipation, no melena, no change in bowel movement 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, no loss of consciousness Musculoskeletal: no myalgia, no arthralgia Physical Examination General: conscious, coherent, in respiratory distress Vital Signs: BP: 150/80 mmHg HR:8 bpm RR: 24 cpm Temp: 37°C Skin: No pallor, no cyanosis HEENT: anicteric sclera, pink palpebral conjunctivae, no alar flaring, no mass, no cervical lymphadenopathies CHEST AND LUNGS: symmetrical chest expansion, no retractions, (+) decreased breath sounds Right with unequal tactile fremitus HEART: adynamic precordium, PMI at 5th ICS left midclavicular line, normal regular rate rhythm, no murmur ABDOMEN: flabby, soft, normal abdominal bowel sounds, non tender EXTREMITIES: grossly normal, no cyanosis, no edema

Assessment:

Secondary Pneumothorax PTB III T/C COPD S/P CTT Insertion (R)

Plan: for ADMISSION Laboratory Requested: Medications: Sputum AFB x 3 days; CXR PA; ECG; CBC with PC; BUN, Crea, SGPT, SGOT

INH+Rifampicin 3 tabs OD pre breakfast

Vitamin B complex 1 tab OD Ibuprofen 200mg 1 tab TID PRN for pain Tramadol 50mg amp 1 amp TIV PRN for pain Course in the Wards: 20 On the first hospital day, diet was maintained. IVF: PNSS 1L x 8. Patient was for repeat CXR PA, daily CTT output monitoring. Patient was maintained on moderate high back rest. VS were monitored q1. 21 On the 2nd hospital day, patient was maintained on low salt, low fat diet with strict aspiration precaution and maintained on PNSS. Other laboratories needed were TG, cholesterol, HDL, LDL, BUA, FBS, BUN, Crea, Na and K. Other medications were continued and Losartan 50 + HCTZ 12.5mg 1 tab OD, captopril 25mg 1 tab sublingual prn for BP> 160/100. Patient was placed on moderate to high back rest.


				
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