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SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: Dr. Silahis O. Rosario


SUBMITTED BY: BUENAVISTA, Casey Brent C. CIMAFRANCA, Louie Mar E.
CABILES, Sigrid Lourdes T. DELMO, Hazel Frans R.

REPRESENTATIVE CASE
IDENTIFYING DATA:
A.D., a 63 year old male, married, lawyer, from this city admitted due to chest pain.
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS:
The condition was noted about a year PTA, as onset of on and off chest pain, described as transient pricking of few seconds to a minute
duration, and occasionally as vague discomfort at the midchest for about 3 5 minutes. This was usually noted after exertion and
relieved with rest. There was occasional epigastric discomfort relieved with burping. However, there was no diaphoresis,
palpitation and shortness of breath. No consultation was done.

6 hours PTA, while at the gym lifting weights, he experienced chest pain/heaviness lasting less than 10 minutes associated with weakness
of the left arm, cold sweats and palpitation. This was relieved after resting.

1 hour PTA, he was awakened due to retrosternal pain, described as squeezing, about 20 minutes, with 7 8/10 pain scale, with radiation to
the back, associated with diaphoresis, palpitation, burning epigastric pain, nausea and shortness of breath thus was brought to
the emergency room (ER).
PAST MEDICAL HISTORY:
He is hypertensive for 5 years on losartan 50mg daily. He is diabetic for 2 years on regular intake of metformin 500mg twice daily. He had
previous elevations in cholesterol and was on atorvastatin for only a month.
PERSONAL AND SOCIAL HISTORY:
He was a smoker of 20 pack years, stopped for 1 year. An occasional alcoholic beverage drinker. He has no regular exercise.
FAMILY HISTORY:
Both parents have hypertension, the father is diabetic. There is no history of sudden death.
REVIEW OF SYSTEMS PHYSICAL EXAMINATION
He has occasional cough and colds, General: He was admitted conscious, coherent, anxious, ambulatory, afebrile, not in respiratory distress
palpitations, easy fatigability, shortness Vital Signs: BP = 100/60 mmHg HR = 104/min RR = 20/min Temp = 36.5 C
of breath, epigastric pain relieved with O2 Sat = 97% Wt = 68 kg Ht = 57
antacids, bloated abdomen and back Skin: warm, sweaty, good turgor
pains HEENT: anicteric sclera, pink palpebral conjunctivae, (-) TPC, (-) NVE, (-) bruit
Chest and Lungs: equal chest expansion, slight tenderness on the left costochondral area, clear breath
sounds
CVS: adynamic precordium, apex beat at the left 5th ICS, MCL, distinct S1 and S2, regular rhythm,
tachycardic, (-) murmur
Abdomen: flabby, NABS, soft, no organomegaly, no tenderness
Extremities: No edema, full pulses
Neuro: within normal
PRIMARY WORKING IMPRESSION
DIAGNOSIS RULE IN RULE OUT
ACUTE CANNOT BE
CORONARY HPI: on and off chest pain, described as transient pricking of few seconds to a minute duration, RULED OUT
SYNDROME: occasionally vague discomfort at the midchest for about 3 5 minutes, discomfort was usually noted
STEMI KILLIP II after exertion and relieved with rest, occasional epigastric discomfort relieved with burping chest
pain/heaviness less than 10 mins associated with weakness of the left arm, cold sweats and
palpitation, relieved after resting
awakened due to retrosternal pain, described as squeezing, about 20 minutes, with 7 8/10 pain
scale, with radiation to the back, associated with diaphoresis, palpitation, burning epigastric pain,
nausea and shortness of breath
PMH: hypertensive for 5 years, diabetic for 2 years, had previous elevations in cholesterol
PSH: was a smoker of 20 pack years, stopped for 1 year, occasional alcoholic beverage drinker, has
no regular exercise
FH: both parents have hypertension, father is diabetic
ROS: has occasional cough and colds, palpitations, easy fatigability, shortness of breath, epigastric
pain, bloated abdomen and back pains
P.E.: anxious, BP = 100/60 mmHg, HR = 104/min, skin is warm and sweaty, slight tenderness on
the left costochondral area, tachycardic
LABS:
12 lead ECG showed sinus rhythm with ST segment elevation at leads 1, aVL and V1-6,
Troponin T = 50 100 ng/mL, CK MB = 18 ng/mL,
WBC = 10,700/mm3, FBS = 136 mg/dL, HBA1C = 7,
Total cholesterol = 259 mg/dL, Triglycerides = 210 mg/dL, HDL C = 40 mg/dL, LDL C = 158
mg/dL, Amylase = 104 U/L,
Chest x ray: cardiomegaly,
2D Echocardiogram: concentric LVH with hypokinesia of the anterior IVS, anterior and anterolateral
LV free wall with ejection fraction of 50%
Ultrasound of the abdomen: Mild fatty liver
DIFFERENTIAL DIAGNOSIS
DIAGNOSES RULE IN RULE OUT
ACUTE ID: predominantly affects males Median age of onset for alcohol related Acute
PANCREATITIS HPI: epigastric discomfort relieved with burping, awakened due to panc. is 39 years old
retrosternal pain, 7 8/10 pain scale, radiation to the back, (-) dull, boring, steady type of pain
associated with diaphoresis, palpitation, burning epigastric pain, (-)pain is sudden in onset and gradually
nausea and shortness of breath intensifies, constant ache
PMH: elevated cholesterol (-)fever, nausea and vomiting
PSH: alcohol beverage drinker (+)NABS
FH: both parents have hypertension, father is diabetic (-)ARDS, pleural effusion
ROS: easy fatigability, shortness of breath, epigastric pain relieved (-) leukocytosis (segmenters In normal range)
with antacids, bloated abdomen and back pains (-) incrased SGPT, amylase,
PE: tachycardic, warm, slight tenderness on the left costochondral
area
LABS: Total cholesterol=259 mg/dl; Triglycerides= 210mg/dl
UTZ of abd: mild fatty liver
AORTIC ID: Men have about double the incidence of aortic dissection, peaks Aortic dissection is relatively uncommon.
DISSECTION in the 60s and 80s. (-) quality of pain is sudden severe chest or
HPI: gym lifting weights, he experienced chest pain/heaviness lasting upper back pain, often described as a tearing,
less than 10 minutes associated with weakness of the left arm, cold ripping or shearing sensation, that radiates to
sweats and palpitation, awakened due to retrosternal pain the neck or down the back
7 8/10 pain scale, with radiation to the back, associated with (-) asymmetric peripheral pulses
diaphoresis, palpitation, burning epigastric pain, nausea and (-) bounding pulses
shortness of breath (-) bibasilar crackles
PMH: hypertensive for 5 years (-) murmur
FH: both parents have hypertension, father is diabetic (-) syncope
ROS: easy fatigability, shortness of breath, epigastric pain, bloated (-) altered mental status
abdomen and back pains (-) numbness and tingling, pain, or weakness in
the extremities
(-) horner syndrome (ptosis, miosis, anhidrosis)
(-) hemoptysis
(-) fever
(-) widening of the mediastinum and
hemothorax in imaging studies
ABDOMINAL ID: age of onset begins at 50 years old in men AAAs are uncommon in Asians
AORTIC ANEURYSM HPI: awakened due to retrosternal pain described as squeezing, 7 (-) pulsation in abdomen or presence of a
8/10 pain scale, with radiation to the back, associated with pulsatile mass
diaphoresis, palpitation, burning epigastric pain, nausea and (-)sudden, severe and constant type of pain
shortness of breath, (-)abdominal bruit
PMH: hypertensive for 5 years
PSH: smoker for 20 pack years
FH: both parents have hypertension, father is diabetic
ROS: easy fatigability, shortness of breath, epigastric pain, bloated
abdomen and back pains
ESOPHAGEAL ID: Incidence increases with age (63 years old) More common in whites
SPASM HPI: chest pain, awakened due to retrosternal pain, with radiation to More common in women than in men
the back, burning epigastric pain (-) globus (the sensation that an object is
LABS: trapped in the throat)
FBS = 136 mg/dL (-) dysphagia
HBA1C = 7 (-) regurgitation
PUD: DUODENAL ID: Younger men are more likely to develop
ULCER HPI: occasional epigastric discomfort relieved with burping, pain that duodenal ulcer
awakens from sleep, 7 8/10 pain scale, with radiation to the (+) chest pain
back(penetrating ulcer). (-) nausea and vomiting
ROS: shortness of breath, epigastric pain relieved with antacids,
bloated abdomen and back pains
RATIONAL LABORATORY & DIAGNOSTIC TESTS
LAB. TEST PATIENT NORMAL INTERPRETATION/NECESSITY AVAILABILITY COST
RESULTS VALUES
HEMATOLOGY
Hemoglobin 12-14gm% 13-16g/dl A CBC test is done to be able to determine SMCFI, HCH, P220.00
Hematocrit 38.8-46.4% 37-44% the blood picture of the patient, because a NOPH, and other
Total WBC 4.5-11T/cumm 4500-11000/cumm patient with anemia can present with chest private laboratories
Neutrophils 55-70% 55-70% pain due to imbalance in oxygen supply
Lymphocytes 20-35% 20-35% and myocardial oxygen demand, but the
Platelets 150-400T/cumm 150-400T patients results are normal and this
indicates that the cause of the chest pain is
not related to anemia, and platelet count is
related to risk stratification and
management because research has
correlated an increased platelet count on
presentation to have poorer in hospital
outcome. A normal platelet count of the
patient indicates that the patient has a
better prognosis.
CLINICAL CHEMISTRY
SGPT 7-56 U/L 20 U/L that can present with chest pain. Cirrhosis, SMCFI, HCH, P240.00
cholelithiasis, and pancreatitis can present NOPH, and other
with chest pain but each of these can be private laboratories
Amylase 104 U/L 104 U/L ruled out because of the history and PE of SMCFI, HCH, P210.00
the patient and also because of these tests NOPH, and other
that are ordered, because each test private laboratories
Serum Uric 5mg/dL 3.6-8.2 mg/dl showed a normal result, and some showed SMCFI, HCH, P220.00
Acid a low normal result. Studies have also NOPH, and other
shown that elevated SGPT levels are also private laboratories
Alkaline 36-92umol/L 30 umol/L associated with worse mortality and clinical SMCFI, HCH,
Phosphatase outcomes in patients with STEMI, and also NOPH, and other P200.00
a high uric acid level can also help in the private laboratories
development of atherosclerosis. These
tests are not only for ruling in and ruling out
diagnosis but also for prognostic and
management values as well.
LIPID PROFILE
Total 259mg/dl <200mg.dl The purpose of this test is to determine the SMCFI, HCH, P 800.00
Cholesterol lipid levels of the patient, this is added to NOPH, and other
LDL 158mg/dl 60-130mg/dl help in the diagnosis and treatment of the private laboratories
Triglycerides 210mg/dl <150mg/dl patient because increased levels of LDL,
HDL 40mg/dl >35mg/dl smoking, hypertension and diabetes
mellitus; which the patient has, increases
the risk for the patient to developing
atherosclerosis and this can disturb the
normal functions of the vascular
endothelium and can cause a decrease in
the blood supply to the heart because of
narrowing of the lumen of the vessel or
cause a thrombotic occlusion of the vessel
causing ischemia of the myocardium
supplied by the vessel and causing the
chest pain experienced by the patient.
FBS
Fasting BS 136mg/dl <100mg/dl A fasting blood sugar and HbA1c is SUMC, HCH, P 140.00
needed to help diagnose the patient to NOPH, and other
have diabetes mellitus, although he was labs
HbA1c 7% <6.5% diagnosed previously to have DM and was SUMC, HCH, P 630.00
treated for it, these tests can help evaluate NOPH, and other
if the patient is properly complying with his labs
medications. This compliance can be seen
in the HbA1c test because this test
measures the patients blood levels in a
span of 3 months and an increased value
indicates the patient to have either poor
compliance or this may indicate a need for
further non-pharmacologic and
pharmacologic management to control it
properly.
KIDNEY FUNCTION TEST
Creatinine 1.0 mg/dL 0.6-1.2 mg/dL This test is used to determine if there is SUMC, HCH, P 170.00
renal disease in the patient and the test NOPH, and other
shows a normal value which indicates that labs
the patient has no kidney problem because
it has been noted that renal disease can
help accelerate atherosclerosis, and it has
also been studied that elevated admission
creatinine levels are associated with
impaired myocardial flow and poor
prognosis in STEMI patients undergoing
primary PCI.
CARDIAC MARKERS
Troponin T 50-100 ng/mL <0.1ng/mL These tests can help determine presence SUMC, HCH, P2,840.50
of necrotic heart muscles due to ischemia NOPH, and other
because cardiac biomarkers are released labs
CK-MB 18 U/L 0-16 U/L from necrotic heart muscles into the blood P610.00
when cardiac lymphatics cant clear out the
interstitium of the infarct zone and causing
overflow of it into the circulation. Although
each of these tests individually are specific
for the myocardium, Troponin T is more
specific and sensitive than CK-MB
because it can detect levels smaller than
the detection limit of CK-MB and also
because it measures the presence of the
Troponin T component in the myofilaments
of the heart which is not seen in other
organs of the body making it more specific,
but either is clinically acceptable for
determining presence of myocardial
damage.

These tests coupled with ECG and other


tests can help in determining the cause of
the chest pain, either it is STEMI, NSTEMI
or UA.
OTHER LABS AND IMAGING STUDIES
12 LEAD ECG Sinus rhythm with An ECG helps in determining the cause of the patients chest pain, SUMC, HCH, P600.00
ST segment and coupled with other tests this can pinpoint the diagnosis of the NOPH, and other
elevation at leads I, patient. The ECG is a graphic recording of the electrical potentials labs
aVL & V1-6 generated by the heart and because of it being noninvasive,
Chest X-ray Cardiomegaly inexpensive and a highly versatile test, it is a valuable tool in the SUMC, HCH, P280.00
emergency room setting in accordance to a patient presenting with NOPH, and other
chest pain because this can be caused by arrhythmias, conduction labs
2D Concentric LVH disturbances and or life threatening metabolic disturbances which SUMC, HCH, P3120.00
Echocardiogram with hypokinesia of are detected on ECG. NOPH, and other
the anterior IVS, labs
anterior and The patients results show an ST segment elevation at leads I, aVL
anterolateral LV & V1-6 and this indicates ischemia on the anterseptal and
free wall with anterolateral walls of the heart due to total occlusion of an
ejection fraction of epicardial artery which causes the ischemia and causes a voltage
50% gradient between normal and ischemic zones of the heart which
Abdominal Mild fatty liver causes the ST segment elevations. SUMC, HCH, P1,300.00
Ultrasound A chest x-ray is warranted in this situation because there is a need NOPH, and other
to see the structures of the chest that could explain the patients labs
signs and symptoms. The patients results showed cardiomegaly,
and this can be caused by hypertension, which the patient has
been experiencing and also it can be a consequence of IHD. This
will also help in the management of the patient.
This test is used to help determine the cause of the patients chest
pain in an emergency room setting and assess the left ventricular
performance and regional wall motion to determine extent of
ischemia, determine prognosis and determine management
decisions in the ER setting. The patients results indicate presence
of ischemia causing the hypokinesia and the concentric LVH can
be caused by the patients hypertension due to cardiac remodeling.
An abdominal ultrasound is added to help determine the cause of
the patients signs and symptoms other diagnosis like cirrhosis,
pancreatitis and cholelithiasis can cause chest pain, this test is
used to help rule in and rule out other diagnosis and also the
patients results shows mild fatty liver and this can help in the
prognosis and management of the patient because a study has
shown that patients after undergoing PCI with NAFLD are more
likely to have impaired myocardial perfusion and poorer outcome if
it is not treated.
FINAL DIAGNOSIS
ACUTE CORONARY SYNDROME: STEMI KILLIP II
DIABETES MELLITUS TYPE II
HCVD,
DYSLIPIDEMIA
NAFLD

PATHOPHYSIOLOGY Disruption of atherosclerotic plaque with a rich lipid
core and a thin fibrous cap in the coronary artery.

Risk factors:
Cigarette smoking
Initial platelet monolayer formation
Hypertension
Lipid accumulation
Collagen,ADP,
epinephrine,
serotonin

Platelet activation

Conformation change in the
Release of thromboxane A2 causing further glycoprotein IIb/IIIa receptor
platelet activation and potential resistant to
fibrinolysis


High affinity for fibrinogen resulting in
platelet cross-linking and aggregation





Formation of platelet plug



Activation of coagulation cascade


Exposure of tissue factor in damage
endothelial cells at the site of the disrupted
plaque

Activation of factor VII and X



Conversion of prothrombin to thrombin



Conversion of fibrinogen to fibrin


Coronary artery becomes occluded by a
thrombus containing platelet aggregates and
fibrin strands



Coronary blood flow decreases abruptly



ST Segment Elevation Myocardial Infarction


THERAPEUTIC MANAGEMENT
LIST OF PROBLEMS THERAPEUTIC OBJECTIVES
1. Chest pain 1. To relieve chest pain.
2. Increased Troponin I 2. To return patients blood sugar levels to normal.
3. Dyslipidemia 3. To maintain normal blood sugar levels.
4. Diabetes Mellitus type 2 4. To reduce triglyceride and low density lipoproteins and
5. Cardiomegaly increase high-density lipoprotein levels.
6. Nonalcoholic Fatty Liver Disease 5. To lower blood pressure level and maintain levels within
normal range.
6. To prevent further complications.
7. To improve the quality of life of the patient.

ADVICE AND INFORMATION NON-PHARMACOLOGIC MANAGEMENT


1. Educate and inform the patient and his family about his A. Prehospital Management
condition. Recognition of symptoms
2. Discuss to them the disease etiology, course, treatment Rapid deployment of an emergency medical team
options and prognosis and on how this can affect the patient Expeditious transportation
and the family. B. Reperfusion Therapy (Fibrinolysis/Thrombolysis)
3. Advice patient to change his lifestyle. Emphasize the 1. Admit patient to ICU.
importance of exercise and a healthy diet. 2. Start IVF with PNSS.
4. Educate patient on the importance of smoking cessation 3. Start O2 inhalation of 2 L/min.
and limiting alcohol intake to 2 glasses / day. 4. Administer thrombolytics such as Streptokinase & TPA.
5. Advice patient to engage to exercise such as brisk walking 5. Additional drugs: Aspirin, clopidogrel, alprazolam, morphine for
for about 30 minutes for 3-4x a week. Emphasize the pain, metoprolol, atorvastatin and senna concentrate. If there is
relationship of the aerobic exercise and his health condition. presence of dyspnea and Bibasal rales add furosemide (20 mg)
6. Patient should be informed on proper blood pressure and perindopril (5 mg).
control. The patients blood pressure should be within 6. Monitor vital signs every 4 hours.
<130/80 mmHg. 7. Blood pressure monitoring every hour for the first 4 hours, then
every 4 hours. Refer BP < 130/80 mmHg.
8. If patient is still in pain, add nitrate drip.
9. Activity:
o 1st 12 hours: bed rest
o Next 12 hours: dangling of feet at bedside and sitting
in a chair
o 2nd and 3rd day: ambulation in the room with
increasing duration & frequency to a goal of 185
meters (600 Ft.) at least 3x a day
10. NPO or only clear fluids for the first 4-12 hours (due to risk of
emesis and aspiration).
11. If patient need to withstand period of enforced inactivity,
sedation maybe required.

PHARMACOLOGIC MANAGEMENT

PRESCRIPTION DRUGS
DRUG NAME EFFICACY SAFETY SUITABILITY COST
Aspirin Aspirin is an analgesic, anti- GI disturbances; Prophylaxis for MI, stent 100's
(Aspec-EC) inflammatory and antipyretic. prolonged bleeding implantation, pain & fever, (P220.00/
It inhibits cyclooxygenase, time, rhinitis, pain & inflammation pack)
Sig. Should be taken which is responsible for the urticaria and associated with
with food: Take synthesis of prostaglandin epigastric musculoskeletal and joint
immediately after and thromboxane. It also discomfort; disorders
meals. Swallow inhibits platelet aggregation. angioedema,
whole, do not Duration: 4-6 hr. salicylism, tinnitus;
chew/crush. bronchospasm.
Clopidogrel bisulfate Clopidogrel selectively Hematoma, Prophylaxis for thromboembolic 75 mg -
(Cardogrel) inhibits adenosine epistaxis, diarrhea, disorders, Acute coronary 14's
diphosphate (ADP) from dyspepsia, syndrome (P385.00/
Sig. ST-elevation binding to its platelet abdominal pain, pack)
MI: In combination w/ P2Y12 receptor and bruising, bleeding
aspirin: 75 mg once subsequent activation of at puncture site.
daily. Loading dose: glycoprotein GPIIb/IIIa Rarely, Stevens-
300 mg for patients complex thus reducing Johnson syndrome,
<75 yr. Continue platelet aggregation. erythema
treatment for at least multiforme, serum
4 wk. sickness, interstitial
pneumonitis, lichen
planus, myalgia.
Fondaparinux is a synthetic Anemia, bleeding, Treatment of acute DVT & 10 1's
Fondaparinux Na and selective inhibitor of purpura; edema. pulmonary embolism (PE), (P14700.
(Arixtra) activated factor X (Xa). By unstable angina or non-ST 00/box)
binding selectively to ATIII, segment elevation MI
fondaparinux potentiates (UA/NSTEMI) acute
(about 300 times) the innate coronary syndrome for the
Sig. 2.5 mg once neutralization of factor Xa by prevention of death, MI &
daily, 1st dose to be ATIII. Neutralization of factor refractory ischemia; ST
given IV & Xa interrupts the blood segment elevation MI
subsequent doses coagulation cascade and (STEMI) acute coronary
given SC for up to 8 inhibits both thrombin syndrome for the
days or until hospital formation and thrombus prevention of death &
discharge. development. myocardial re-infarction in
patients who are managed
w/ thrombolytics or who
initially are to receive no
other form of reperfusion
therapy.
Metoprolol succinate Metoprolol selectively inhibits Fatigue, dizziness, Mild to moderate HTN, Angina 100's
(Betazok) 1-adrenergic receptors but headache; pectoris or cardiac arrhythmias, (P2843.0
has little or no effect on 2- bradycardia, MI, Functional heart disorders w/ 0/pack)
receptors except in high postural disorder, palpitations, Migraine prophylaxis,
doses. It does not exhibit cold extremities, Chronic heart failure
membrane stabilizing or palpitations;
Sig. 200 mg once intrinsic sympathomimetic nausea, abdominal
daily. activity. pain, diarrhea,
constipation,
dyspnea on
exertion.
Captopril Captopril competitively Nonproductive HPN, Heart failure, Post MI, 100's
(Captril) inhibits the conversion of cough, dyspnea, Diabetic nephropathy (P998.00/
angiotensin I (ATI) to headache, pack)
Sig. Should be taken angiotensin II (ATII), thus abdominal pain, dry
on an empty resulting in reduced ATII mouth, dizziness,
stomach: Take on an levels and aldosterone GI and taste
empty stomach 1 hr secretion. It also increases disturbances, sleep
before or 2 hr after plasma renin activity and disorders.
meals. May be bradykinin levels. Reduction Hypotension,
started 3-16 days of ATII leads to decreased tachycardia, chest
after MI. Initially, 6.25 Na and water retention. This pain, palpitations,
mg/day followed by promotes vasodilation and hyperkalemia,
12.5 mg tid for 2 BP reduction. hyponatremia,
days, then 25 mg tid. gynecomastia
Maintenance: 75-150 (reversible).
mg/day in 2 or 3 Pruritus, skin
divided doses. rashes, alopecia.
Atorvastatin Ca Atorvastatin competitively Thrombocytopenia, Treatment of primary 100's
(Atormax) inhibits HMG-CoA reductase, acute hepatitis, hypercholesterolemia, (P16.00/f
the enzyme that catalyzes muscle disorders, heterozygous & ilm-
the conversion of HMG-CoA toxic epidermal homozygous familial coated
to mevalonate. This results in necrolysis. hypercholesterolemia or tab,
Sig. Initially 10 mg the induction of the LDL combine hyperlipidemia in P1600.00
daily. May be receptors and stimulation of patients who have not /box)
adjusted at intervals LDL catabolism, leading to responded adequately to
of 4 week up to max lowered LDL-cholesterol diet & other appropriate

of 80 mg daily. levels. measures.
MONITORING AND FOLLOW-UP
1. Check if there was a complete cessation of smoking by the 4. Monitor patients vital signs: BP, BMI, weight
patient. 5. Follow up on patients physical activity.
2. Check patient if there are any signs of complications. 6. Monitor on patients compliance to his medications.
3. Repeat lab tests: FBS, HbA1c, Lipid panel


PRESCRIPTION WRITING


DR. HAZEL FRANS DELMO DR. HAZEL FRANS DELMO

SILLIMAN UNIVERSITY MEDICAL CENTER SILLIMAN UNIVERSITY MEDICAL CENTER

Patient: AD Date: 06-27-16 Patient: AD Date: 06-27-16

Address:Dumaguete City Age/Sex: 63 yo/M Address:Dumaguete City
Age/Sex: 63 yo/M




































HAZEL FRANS DELMO MD HAZEL FRANS DELMO MD

Lic. No. 123456786 Lic. No. 123456786




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