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					                                                  CLINICAL HISTORY

Demographic Data:
                                                             nd
      MM, 18 year old male from Paranaque, admitted for the 2 time at this institution.

Chief Complaint:
       Difficulty of breathing and chest pain of 2 weeks duration.

Patient Profile:
Patient is a diagnosed case of Rheumatic Heart Disease since 2003.
     initially presented with chest pain, DOB, body weakness and bipedal edema
     maintained on Lanoxin         1 tab BID, Captopril 25mgTID, Furosemide 20mg BID & Pen G IM q21 days, with
         good compliance to medications
     lost to follow-up since July 2009

History of Present Illness:
2 weeks PTA      (+) exertional dyspnea when walking 20 meters on level ground
                 (+) occasional chest pain, crushing, VAS 5/10, relieved with rest and with massage
                 (-) consult, compliant to maintenance meds
1 week PTA       (+) difficulty of breathing
                 (+) chest pain, (+) 4 pillow orthopnea
                 (-) fever, joint pains, cough
                 (-) consult, compliant to maintenance meds
3 days PTA       Persistent symptoms
                 (+) oliguria
                 (+) progressive dyspnea, even at rest
                 (+) increase frequency of episodes of chest pain
Few hrs PTA      Increase intensity of chest pain to 8/10

Review of Systems:
    +      (+) anorexia                                          (+) good appetite
           (-)   fever                                           (-)   colds and cough
           (-)   headache                                        (-)   palpitations
    -      (-)   nausea and vomiting                             (-)   joint pains
           (-)   bowel changes                                   (-)   abdominal distention

Past Medical History:
       2003: admitted at this institution due to chest pain, DOB, body weakness, bipedal edema
             Diagnosed with RHD
       No known allergy to food and drugs

Family History:
       PTB: father (lives in Bicol)
       (-) DM, HPN, Ca, BA

Birth and Maternal History:
     born to a then 23 yr old G1P0 via SVD at home, by a midwife; with good cry and activity, (-) FMC
     (-) PNCUs;(-) maternal illnesses

Immunization History:
    Mother claims given primary immunizations at LHC but unrecalled specific vaccines.

Feeding History:
    eats regular table food, not picky

Developmental History:
    at par with age

Personal Social History:
    eldest in a brood of 3; stopped going to school at elementary due to medical condition
        parents separated
             o mother, 41, laundrywoman
             o father, 37, unemployed

                                                     PHYSICAL EXAMINATION

General Survey:             awake, conversant and coherent, ambulatory, in mild cardiorespiratory distress

 BP 100/70                        HR 76                    RR 20                T 36.2 C            Wt 47.3 kg

HEENT:                      pale palpebral conjunctivae, dirty sclera, no aural or nasal discharges, no tonsilopharyngeal
                            congestion, (-) cervical lymphadenopathies, (-) anterior neck mass, (+) bilateral neck vein
                            engorgement, JVP 11 cm (30 degrees)

Chest & Lungs:              Equal chest expansion, decreased breath sounds on the LLLF

Cardiovascular:             dynamic precordium, normal rate, regular rhythm, apex beat at 5th ICS LAAL
                            Grade 2/6 holosystolic murmur heard best at 2 nd ICS LPSB, Grade 1/6 diastolic
                            murmur heard at 4th ICS LPSB

Gastrointestinal:           flat abdomen, normoactive bowel sounds, liver edge palpable 3cm below left subcostal
                            margin, (-) masses, (+) tenderness at left upper quadrant and epigastric areas on deep
                            palpation

Skin and Extremities:       full and equal pulses, pale nail beds, (-) cyanosis, (-) clubbing, (+) grade 2 nonpitting
                            bipedal edema

WBC             4-11x109/L          15.4                           BUN            3.2-8.0 mmol/L     63.29
RBC             4-6x1012/L          2.60                           Creatinine     53-133umol/L       203
Hgb             120-180g/L          66                             Sodium         135-145mmol/L      121
Hct             0.370-0.540%        0.200                          Potassium      4.0-4.5mmol/L      4.4
MCV             80-100fL            76.9                           Chloride       99-110mmol/L       83
MCH             27-31pg             25.4                           Calcium        2.12-2.75mmol/L    1.95
MCHC            320-360g/L          330                            Albumin        38-51g/L           22
RDW-CV          11-16%              17.0                           AST (SGOT)     0-34U/L            22
Platelets       150-450x109/L       257                            ALT (SGPT)     0-30U/L            37
                                                                   TB             0-17.1umol/L       12.70
Neut%           0.5-0.7             0.886                          DB             0-3.42umol/L       6.73
Lymph%          0.2-0.5             0.063                          IB             3.4-13.7umol/L     5.97
Mono%           0.02-0.09           0.048
Eo%             0.0-0.06            0.002
Baso%           0.0-0.02            0.001


Urinalysis
Light yellow, clear, 1.015, (-) sugar, (-) prot, (-)
cast/crystals, RBC 0-2/hpf, WBC 0-1/hpf, EC occ,
bact occ, (-) MT, (-) bil, (-) leuc, (-) nitrite, normal
urobil, (-) ketone



                                                           ASSESSMENT

Congestive Heart Failure, Functional Class III secondary to Rheumatic Heart Disease
                                                       PLAN
Limit OFI to 1.6L/day
Complete bed rest without bathroom priviledges
Transfuse 4 ‘u’ pRBC properly typed and coss-matched

Therapeutics:
Furosemide (1) 4mg IV q8, defe for BP <90/60
Lanoxin (2.5) 125 mcg/tab, ½ tab BID
Captopril (1.5) 25mg/tab, 1 tab TID
Dopamine (10) 5.7cc in 34.3cc D5W to run 5cc/hr
CaCO3 500mg/tab, 1 tab TID
NaCl tabs, 1 tab OD

				
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posted:9/23/2011
language:English
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