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
