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    Candy MI

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    Candy Paraiso Agustin
    A 70-year-old Filipino man presented with a 1-week history of productive cough, difficulty breathing, and undocumented fever. He developed sudden onset of severe chest pain and easy fatigability. Exam found crackles and retractions. Labs showed anemia and elevated troponin. ECG showed sinus tachycardia. He was admitted with impressions of NSTEMI, ADHF, COPD, and DM. Medical management included IV fluids, antibiotics, diuretics, aspirin, and monitoring.

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    Candy MI

    Uploaded by

    Candy Paraiso Agustin
    20 views40 pages
    A 70-year-old Filipino man presented with a 1-week history of productive cough, difficulty breathing, and undocumented fever. He developed sudden onset of severe chest pain and easy fatigability. Exam found crackles and retractions. Labs showed anemia and elevated troponin. ECG showed sinus tachycardia. He was admitted with impressions of NSTEMI, ADHF, COPD, and DM. Medical management included IV fluids, antibiotics, diuretics, aspirin, and monitoring.

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    A 70-year-old Filipino man presented with a 1-week history of productive cough, difficulty breathing, and undocumented fever. He developed sudden onset of severe chest pain and easy fatigability. Exam found crackles and retractions. Labs showed anemia and elevated troponin. ECG showed sinus tachycardia. He was admitted with impressions of NSTEMI, ADHF, COPD, and DM. Medical management included IV fluids, antibiotics, diuretics, aspirin, and monitoring.

    Copyright:

    © All Rights Reserved
    Download as KEY, PDF, TXT or read online from Scribd
    Download as key, pdf, or txt
    20 views40 pages

    Candy MI

    Uploaded by

    Candy Paraiso Agustin
    A 70-year-old Filipino man presented with a 1-week history of productive cough, difficulty breathing, and undocumented fever. He developed sudden onset of severe chest pain and easy fatigability. Exam found crackles and retractions. Labs showed anemia and elevated troponin. ECG showed sinus tachycardia. He was admitted with impressions of NSTEMI, ADHF, COPD, and DM. Medical management included IV fluids, antibiotics, diuretics, aspirin, and monitoring.

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    © All Rights Reserved
    Download as KEY, PDF, TXT or read online from Scribd
    Download as key, pdf, or txt
    of 40

    Admission Conference

    General
    70 years old
    Data
    Male

    Married

    Born on March 17, 1949

    Filipino

    Currently residing at Meycauan, Bulacan

    Roman Catholic

    admitted for the 1st time at Fatima


    University Medical Center on July 15,
    2019.
    Chief complaint

    Chest pain
    History of
    1 week PTA
    Present Illness
    productive cough with yellowish sputum
    amounting to 1tbsp

    associated with difficulty of breathing upon


    exertion, diaphoresis and undocumented
    fever.

    No other signs and symptoms noted such


    orthopnea, dizziness, paroxysmal nocturnal
    dyspnea.

    Medication taken salbutamol inhaler 2puff


    which provided temporary relief.

    No consultation done.
    History of Present Illness

    3 days PTA

    still with the above signs and symptoms

    now with easy fatigability.

    Patient sought consult to a private MD and


    was advised for admission but refused.
    2 days PTA

    still with the above signs and symptoms

    After eating lunch, patient had sudden onset


    of substernal, chest pain upon mild exertion,
    graded as 8/10, stabbing in character, non-
    radiating, and last for 20minutes.

    Patient went to a public institution and was


    subsequently admitted.

    FHPTA, the patient’s daughter who was an


    employee of OLFU- Antipolo advised him to
    transfer in our institution due to financial
    advantages.
    Past Medical History
    (-) HPN

    (+) DM 2 years highest CBG 200+, meds: Galvus


    met 50/500mg/tab OD

    (+)COPD 10 years, meds: Salbutamol inhaler 2puff

    (+) Surgery - appendectomy,1994

    (-) Allergy

    (-) Bronchial asthma

    (-) Thyroid disease

    (-) Myocardial infarction

    (-) Stroke
    Family History
    (+) Emphysema - maternal (deceased)

    (+) Lung mass - brother

    (-) DM

    (-) HPN

    (-) CVD
    Personal & social history
    Previously smoker 80 pack/years

    Started 20 years old, Frequency 40 sticks/day, Duration 40 years

    Previously occasional alcoholic drinker 1-3x/month

    (-) Illicit drug use


    ROS
    General: (-) weight loss, (-) weight gain,(-) chills, (-) body
    weakness
    Skin: (-)color change,(-) sores,(-)rash, scaling, (-)bleeding, (-)
    pruritus
    Head and Neck: (-) nose pain, (-) Otalgia, (-) Tinnitus, (-) Sore
    throat,
    Respiratory: (-) cyanosis, (-) Hemoptysis,(-) Paroxysmal Nocturnal
    Dyspnea
    Cardiovascular:(-) Palpitations, (-) previous episodes of chest
    discomfort
    Gastrointestinal:(-) Abdominal Pain, (-) Diarrhea, (-) Constipation,
    (-) changes in stool caliber, (-) dark colored stools, (-)
    melena, (-) Hematochezia,(-) Hematemesis,
    Genitourinary: (-) Hematuria, (-) Urinary incontinence, (-)
    retention, (-) weak stream, (-) dysuria,(-) Nocturia, (-) Anuria, (-)
    Polyuria, (-) Oliguria, (-) changes in color and volume of urine
    Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) heat/cold
    intolerance
    Hematologic: (-) pallor, (-) easy bruising, (-) easy fatigability,
    Neuropsych: (-) seizure, (-) tremors, (-) depression, (-)
    hallucinations,(-) tingling sensation, (-) numbness, (-) pains
    Musculoskeletal: (-) Muscle pains, (-) Joint Pains, (-) Back pains
    Physical Examination
    Conscious and coherent
    Oriented to time, place and person.
    Fairly nourished, clean, wearing a Tshirt and
    pants.
    No gross deformities noted.
    The patient is ambulatory, afebrile and in
    respiratory distress.
    Vital signs
    BP = 100/80 mmHg
    HR = 105 bpm
    RR= 32 cpm
    Temp = 36.4 C
    Physical Examination
    Skin: Fair in color, no rashes, no masses,
    hair is equally distributed, warm to touch,
    dry, with good skin turgor. Capillary refill
    time of <2 seconds. No clubbing.

    HEENT
    Anicteric sclera
    pink palpebral conjunctiva
    no nasoaural discharge
    No flaring of ala nasi
    lips are dry
    no tonsillopharyngeal congestion
    no cervical lymphadenopathy.
    Physical Examination
    CHEST AND LUNGS
    Respiratory rate is 32 bpm with normal depth
    and rhythm.
    Chest expansion is symmetric with retractions
    at supraclavicular area.
    Crackles are heard bibasal.
    Physical Examination
    CVS
    The precordium is adynamic.
    Chest wall has no tenderness, no masses.
    The apical pulse is palpable at the 5th ICS
    LMCL on supine position.
    The apical beat is 83 beats per minute, regular
    in rhythm.
    S1 is louder than S2 at the apex.
    S2 is louder than S1 in the base.
    No S3 or S4 heard.
    Physical Examination
    ABDOMEN
    Abdomen is flabby.
    There is a 3 inch dry, surgical scar at
    umbilicus area due to post appendectomy.
    Bowel sound is 11 cycles per minute upon
    auscultation- normoactive.
    Abdomen exhibits general tympanism.
    Abdomen is soft with no tenderness or
    rigidity.
    EXTREMITIES
    Grossly normal extremities, no edema, no
    cyanosis.
    Salient Features
    sudden onset of chest pain graded as 8/10, stabbing in character, non-radiating, and lasting for
    20minutes
    70 years old
    productive cough with yellowish sputum
    difficulty of breathing upon exertion, diaphoresis and undocumented fever.
    easy fatigability
    (+) DM
    (+)COPD
    (+) History of surgery
    Previously smoker 80 pack/years
    Previously alcoholic drinker
    BP 100/80mmHg

    HR = 105 bpm

    RR= 32 cpm
    (+) Crackles bibasal
    (+) chest retraction supraclavicular
    Impression

    Acute coronary syndrome, NSTEMI, killips IV,


    ADHF, NYHA 3, HCVD, Type 2 DM, COPD
    Differential Diagnosis
    Aortic dissection

    Rule in Rule out

    70 years old cannot ruled out

    Sudden onset of chest pain

    Difficulty of breathing

    History of smoking

    RR: 32 bpm

    HR: 102 cpm


    Differential Diagnosis
    Pulmonary embolism
    Rule in Rule out

    (+) Productive cough with yellowish


    sputum cannot ruled out

    (+) Difficulty of breathing

    (+) sudden onset of chest pain

    Hypotension 100/80mmHg

    (+) Tachycardia 105cpm

    (+) RR 32 bpm

    (+) History of surgery


    Differential Diagnosis
    Pneumonia

    Rule in Rule out

    70 year old cannot be ruled out

    (+) Productive cough with yellowish


    sputum

    (+) Difficulty of breathing

    Undocumented fever

    (+) easy fatigability

    (+) crackles bibasal

    (+) supraclavicular retraction


    Laboratory test & Ancillary
    Procedure
    CBC Result Normal Value
    WBC 9.4 5.00-10.00 x 10^9/L
    Neutrophils 0.82 H 0.40-0.60
    Lymphocytes 0.13 0.20-0.40
    Monocytes 0.4 0.02-0.08
    Eosinophils 0.01 0.01-0.03
    Basophils 0.00 0.00-0.02
    Hemoglobin 139 L 140.00-175.00 g/L
    Hematocrit 0.43 0.37-0.42
    RBC 4.4 L 5.50-6.50 x 10^12/L
    MCV 96.1 88.00-96.00 fL
    MCH 31.5 27.00-33.00 pg
    MCHC 327 330.00-360.00 g/L
    RDW 13.1 12.70-22.70 %
    Platelet 288 150.00-450.00 x 10^9/L
    MPV 7.6 4.50-7.50 fL
    PDW 3.17-39.10%
    Laboratory test & Ancillary
    Procedure
    Rate: 1500/17= 88bpm

    Rhythm: Regular sinus rhythm

    Intervals P wave: 0.08 PR: 0.12 QRS: 0.08 QT:0.36


    Laboratory test & Ancillary
    Procedure

    Lead 1 : QRS up AVF: QRS up


    Nomal axis
    Troponin I

    Result Unit Reference

    <1.0 negative >1.0


    4.9 Ng/mL
    positive
    Creatine

    BUN

    Potassium

    Sodium

    Ionized calcium

    Serum magnesium

    Chloride 90.90 L (98.00-107.00)


    Medical Plan

    Admit at ICCU

    IVF PNSS 1L for 16H

    Diet: NPO temporarily

    Laboratories : CBC, BUN, Crea, Serum Elec, 12L ECG, CXR


    portable, ABG, CBG now then TID, Trop I, Ionized Ca, Serum
    Magnesium, Sputum GSCS, Sputum AFB, 2D echo
    Therapeutics
    Piperacillin Tazobactam 4.5g TIV Q8
    Levofloxacin 500mg/tab 1tab OD
    Furosemide 40mg TIv Q8 with BP precaution
    Dopamine drip 800cc in 250cc PNSS to run at 5hours, titrate accordingly
    Aspirin 80mg/tab 1tab OD
    Clopidogrel 75mg/tab, 1tab OD
    Trimetazidine 35mg/tab, 1tab BID
    Clexane 0.4cc SQ BID
    N acetylcystein 600mg/tab 1tab in 1/2 glass of water OD
    Combivent nebulization Q8
    Lactulose 30cc ODHS
    Pantoprazole 40mg TIV OD pre BF
    Jardiace 10mg/tab 1tab OD
    Coralan 5mg/tab, 1tab OD
    Dilatair 200mg/tab, 1tab BID

    Monitor VS q1
    Monitor I and O
    Non- ST-Segment Elevation
    ACS
    caused by an imbalance between myocardial
    oxygen supply and demand
    (1) disruption of an unstable coronary plaque that leads to
    intracoronary thrombus formation and an inflammatory response;

    (2) coronary arterial vasoconstriction;

    (3) gradual intraluminal narrowing

    (4) increased myocardial oxygen demand produced by


    conditions such as fever, tachycardia, and thyrotoxicosis in the
    presence of fixed epicardial coronary obstruction.
    Features of chest discomfort
    (1) occurrence at rest (or with minimal
    exertion), lasting >10 min;
    How to diagnose
    (2) of relatively recent onset (i.e., within the
    STEMI? prior 2 weeks); and/or
    (3) a crescendo pattern
    ECG
    New and deep T-wave inversions (≥0.3
    mV).
    Abnormally elevated levels of
    biomarkers
    Management
    Long term management
    Risk-factor modification

    smoking cessation

    achieving optimal weight

    daily exercise

    blood-pressure control

    appropriate diet

    control of hyperglycemia

    lipid management

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