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    Admission Conference: Ernesto V. Ignacio JR

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    ernignacio
    To serve as a guide in creating a presentation of an actual case handled in the Hospital to present to colleagues and other associated personnel

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    Admission Conference: Ernesto V. Ignacio JR

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    ernignacio
    57 views17 pages
    To serve as a guide in creating a presentation of an actual case handled in the Hospital to present to colleagues and other associated personnel

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    To serve as a guide in creating a presentation of an actual case handled in the Hospital to present to colleagues and other associated personnel

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    57 views17 pages

    Admission Conference: Ernesto V. Ignacio JR

    Uploaded by

    ernignacio
    To serve as a guide in creating a presentation of an actual case handled in the Hospital to present to colleagues and other associated personnel

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 17

    Admission Conference

    Ernesto V. Ignacio Jr.


    • FEF
    • 60 y.o / Male
    • Married
    • Unemployed
    • Valenzuela City
    Patient would experience chest pain described as “heaviness” graded 7/10 that would radiate to the
    1 back and last for 30 seconds which would be relieved by rest. No headache, dizziness, nausea,
    month vomiting and dyspnea were noted. No medications were taken. No consult was done
    PTA

    Interval history showed frequency of chest pain that would still radiate to the back and increase in
    severity. Still no headache, dizziness, nausea, vomiting and dyspnea were noted. No medications were
    taken. No consult was done.

    17 hrs Patient experienced chest pain while cleaning which he described as “nadaganan” graded 10/10 that
    PTA would radiate to the back and was not relieved by rest. Patient then consulted at the ER in Medical
    Center-Valenzuela where Troponin I was done and resulted to be elevated 3.69 ng/mL. The patient
    was given Isosorbide dinitrate 5mg sublingual, 4 tablets of aspirin, 4 tablets of clopidogrel and
    Tramadol IV. The physician in Medical Center-Valenzuela advised to consult a tertiary hospital that
    would better accommodate the patient’s treatment hence admission
    Past Medical History
    (-) HTN
    (-) DM
    (+) PTB – completed 6 months of treatment (2005)
    (-) CA
    (-) Thyroid disorders
    (-) Asthma
    (-) Arthritis

    Previous Hospitalization: 2011 – Motor Vehicle Accident


    Family History
    (+) MI – father and brother
    (-) stroke
    (-) DM
    (+) Cancer – Lung Cancer- brother
    Personal and Social History
    Previous smoker – 44 pack-years
    Occassional alcoholic beverage drinker
    Denies illicit drug use
    No known allergy to food or drugs
    Diet consists of rice fish and vegetables with occasional meat intake
    Review of Systems
    General: conscious, coherent, not in distress (-) fever (-) loss of appetite
    Skin: (-) hair loss (-) pruritus, (-) pallor (-) jaundice, (-) petechiae
    Eyes: (-) change in vision, (-) eye discharge
    HEENT: (-) headache, (-) ear discharge, (-) tinnitus, (-) vertigo, (-)
    epistaxis, (-) change in sense of smell, (-) colds, (-) sinus pain, (-) sore
    throat, (-) gum bleeding
    Respiratory: (-) colds, (-) cough
    Cardiovascular: see HPI
    Review of Systems
    Gastrointestinal: (-) pain, (-) constipation, (-) diarrhea, (-) hematemesis, (-)
    hematochezia (-) vomiting
    Genitourinary: (-) dysuria, (-) hematuria, (-) frequency, (-) urgency, (-)
    nocturia, (-) hesitancy, (+) weak urinary stream, (+) dribbling
    Hematologic : (-) pallor, (-) gum bleeding, (-) easy bruisability
    Endocrine (-) polyuria, (-) polydipsia, (-) polyphagia, (-) cold intolerance, (-)
    tremors
    Nervous: (-) headache, (-) seizures
    Musculoskeletal: (-) swelling (-) knee pains (-) myalgia
    Behavior/Psychiatric: (-) behavioral changes, (-) restlessness
    Physical Examination
    General: Conscious, coherent, not in cardiorespiratory distress, oriented to 3
    spheres
    BP: 150/90 PR: 82 bpm RR: 17 cpm O2 98% Temp: 36.2°C Wt: 65 kg Ht: 172.7
    cm
    Skin: warm, not dry, no pallor, no jaundice
    Head: no facial asymmetry
    Eyes: pink palpebral conjunctiva, anicteric sclera, isocoric pupils 2-3 mm ERTL
    Ear: normal set ears, no aural discharge, no tragal tenderness
    Nose: nasal septum midline, no nasal discharge, non-congested turbinates
    Throat: non-hyperemic, no enlarged tonsils
    Mouth: moist lips and buccal mucosa, no oral ulcers, non-hyperemic posterior
    pharyngeal wall, tonsils not enlarged
    Physical Examination
    Repiratory: symmetrical chest expansion, equal vocal and tactile
    fremiti, resonant on all lung fields, normal breath sounds
    Cardiovascular: adynamic precordium, no heaves/thrills/lifts, rhythm
    regular, apex beat at 6th LICS AAL, loud s1 followed by soft s2 at the
    apex, soft s1 followed by loud s2 at the base, no murmurs
    Gastrointestinal: flat, flabby, normoactive bowel sounds, tympanitic on
    percussion, no direct or rebound tenderness on all quadrants.
    Genitourinary: (-) CVA tenderness
    Extremities: (-) bipedal edema, (-) deformities, (-) cyanosis, pulses full
    & equal
    Subjective Objective
    60, Male Vital signs: BP 150/90 mmHg; PR 92 bpm, regular;
    RR 17 cpm; T 36.20C;

    (+) chest pain No sensory deficit


    BMI=23
    Family History : (+) MI – father and brother

    (-) HTN

    (-) DM

    (-) Thyroid dse


    NYHA Functional Classification
    Stage Description
    I Symptoms occur with greater than ordinary
    physical activity
    II Symptoms occur with ordinary physical
    activity

    III Symptoms occur with less than ordinary


    physical activity

    IV Symptoms occur may be present even at rest


    ACC/AHA Stages of Heart Failure
    Stage Description
    A At high risk for HF but without structural
    heart disease or HF symptoms
    B Structural heart dse but without signs or
    symptoms of HF
    C Structural heart disease with previous or
    current symptoms of HF
    D Refractory HF requiring specialized
    interventions
    Impression

    • ASHD, CAD, NSTEMI, not in failure class IIB


    Plans
    • Diet 30 kcal/kg/day 60% CHO, 25% fats, 15% CHON, <4g Na, <200g
    cholesterol, <7% saturated fats, divided into 3 meals and 2 snacks.
    • Monitor I & O q shift and record
    • Monitor VS every hour and record
    • Ideally for ICU admission, however, due to financial constraints, opted
    to be admitted at a regular ward
    Diagnostics
    • CBC with platelet
    • BUN, Na, K, Crea
    • Urinalysis
    • 12L ECG
    • CXR
    • FBS, lipid profile
    • 2D Echo with Doppler
    • Troponin I
    • Ca, Mg
    Therapeutics
    • Aspirin 80mg/tab 4 tabs now then 1 tab OD
    • Clopidogrel 75mg/tab 4 tabs now then 1 tab OD
    • Atorvastatin 80mg/tab 1 tablet at bedtime
    • Enoxaparin 0.6 cc BID
    • Trimetazidine 35mg/tab 1 tab BID (every 12 hours)
    • Bisoprolol 2.5 mg/tab 1 tab OD
    • Omeprazole 40 mg/tab (Risek) 1 tab, 30 minutes pre-breakfast
    • Lactulose 30 cc OD before bedtime

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