Name: Almaz Zergaw 68, f, married, office worker, protestant, addis ababa
Admission date: april 6
Previous admission: 5 yrs ago for acute Ml
Cc: chest pain of 2 days duration
This is a known T2DM and hypertensive patient each for the past 5years on Glyburide 20mg po qd,
enalapril 25mg po qd, metoprolol 12.5mg qd, Aspirin 100mg po who presented with the above cc.
The chest pain had a sudden onset; ·it Ivas characterized as stabbing type of pain on the middle anterior
chest that radiated to the left shoulder and a -n. It was moderate in severity and was intermittent
occurring for 30 minutes. She was in her office while this happened.
She had past history of STEMl 5 years ago and was treated. She claims she is adherent to her
medications. She denies history of SOB, diaphoresis, exertional dyspnea, Orthopnea, PND, intermittent
claudication, hx of stroke and dyslipidemia. She has family history of bleeding disorder but no other
medical illnesses. o history of fever, nausea, vomiting, diarrhea. She doesn't smoke or drink alcohol. She
denied history of chest trauma, cough, SOB, sputum(hemoptysis), sweating, exertional dyspnea,
orthopnea, PND, and extremity swelling. No history of intermittent claudication, calf pain, recent
surgery/hospitalization, long distance travel (air plane) [recent immobilization]. No previous history of
DVT, PE, but has family hx of bleeding disorder. No known history of malignancy, use of contraceptives.
No hx of weight loss, night sweat, contact to a known TB pt or chronically coughing person. No pain
upon swallowing.
No history of vomiting, nausea, diarrhea, constipation, jaundice, itching, no change in urine/stool color.
She doesn’t have headache, syncope, ABM, or change in mentation.
She frequent! eats salad as well as fatty food. She used to exercise regular! but stopped recently.
She has glucometer and digital BP measuring apparatus at home and regulary checks her blood sugar
and BP regularly. Her avg BP is 120/80 with occasional raise to 140/90. Her recent RBS was around 200.
She doesn’t have baseline HgA1c measurement. She doesn’t have regular diabetic followup at a hospital
(but her husband is a doctor). She doesn’t have blurring of vision, tingling sensation, early satiety,
diarrhea, constipation, polyuria, polydipsia, increased hunger. No hx of UTI.
PHYSICAL EXAM:
G/A: comfortably sitting
Vital signs
BP: 110/80mmHg, taken from the Right brachial artery at supine position
HR: 88 bpm at ER , regular & full in volume, taken from the right radial artery.
Arterial: Carotid,Brachial, femoral, popliteal, posterior tibialis, dorsalis pedis felt bilaterally symmetrical.
RR: 20 per minute, nml pattern and rhythm.
T: 36.6 C from axilla
SpO2: 95% at Room air
Wt, BMI:
HEENT:
Head: atraumatic, normocephalic
EYES: ?slightly icteric sclera, pink conjunctiva
EARS: no swelling or discharge,
Nose: no epistaxis, no discharge
Mouth: wet buccal mucosa
Neck—Trachea midline. Neck supple;
Lymphoglandular system—No preauricular, postauricular, occipital, submandibular, submental, anterior
and posterior cervical, supraclavicular and axillary lymphadenopathy
Inguinal LN not palpated
thyroid isthmus palpable, lobes not felt.
CHEST:
Inspection:
He has normal depth and pattern of breathing. No finger clubbing, no central cyanosis.
Chest is symmetrical.
No visible deformity, use of accessory muscles (sternocleidomastoid, intercoastal muscles). No
sub costal retraction.
Palpation:
No tenderness, trachea is in the midline
Tactile fremitus is bilaterally felt equal
Symmetric chest expansion
Excursion: 4 cm
Percussion
Resonant all over
Auscultation
Clear air entry bilaterally. Vesicular breath sound heard
Cardiovascular system
Arterial: Radial Pulse bpm-full and regular
Carotid, and Brachial felt bilaterally symmetrical.
Lt and Rt dorsalis pedis palpable full and regular.
No carotid bruits
Venous:
JVP: not raised, hepatojugular reflex- not done
Precordial examination
Inspection: quiet precordium, no visible apical pulsation
Palpation: No heaves or thrills
PMI: felt at 5th ICS, at the midclavicular line
Auscultation: S1 & S2 well heard.
No murmur, gallop or added heart sounds (S3 & S4).
Abdomen:
Inspection: protuberant abdomen that moves with respiration, inverted umbilicus, no visible
dilated veins, peristalisis.
Auscultation: Normoactive bowel sounds. No renal bruits appreciated
Palpation: no direct or rebound tenderness, no mass felt
Liver: 10 cm in size along MCL
Spleen: impalpable (in the traubes space)
Percussion: tympanic throughout
PR: not done
GU: NO suprapubic or CVA tenderness, Kidney and bladder not palpable
MSK: no leg edema. Intact range of motion.
SKIN: no skin lesion
Nails: no clubbing of fingers or splinter hemorrhage.
NEUROLOGIC EXAM:
COTPP. No meningeal signs (No neck stiffness. Kerning and brudzki’s were negative )
Cranial nerves: Grossly intact
Motor:
Inspection: no abnormal body movement, no spontaneous and triggered fasciculation.
Bulk: comparable muscle bulk on both UL and LL. no atrophy
Tone: normotonic
Power: 5/5 on all (upper and lower) right and left extremities.
Deep tendon Reflexes
Biceps Triceps Brachioradialis Patellar(knee) Ankle Babinski(plantar)
Lt +2 +2 +2 +2 1 Down going
Rt +2 +2 +2 +2 1 Down going
Assessment: Acute Myocardial infarction
Type 2 Dm on treatment
HTN
Labs: HgA1c: 10.3
Troponin: 13,67
Electrolyte: Na: 142, K: 4.2, CL: 106
BUN: 9, Cr: 0.6
HBsAg and Anti HCV: negative
ECG: showed ST segment elevation on
Echo: grade I diastolic dysfn, mild Tric Regur, mild LVH, EF: 66%
2016: LDL was 105(max is 100)
Current meds:
Enalapril 25mg po qd
Aspirin 100mg po qd,
Clopidogrel 75mg po
Enoxaparini 60IU sc
Atorvastatin 80mg
Metoprolol 12.5mg po bid
Omeprazole 40mg IV
Cimetidine 200mg
