CLINICAL ABSTRACT

Patients Initials: R.V.T.

Age: 59 years old
Gender: Male
Birthday: December 10, 1955
Admitting Diagnosis: T/C Acute Coronary Syndrome 2o Acute Myocardial Infarction
Final Diagnosis: Cardiogenic Shock 2o Myocardial Infarction, 2o Coronary Artery
DiseaseMalignant Arrythmia, CKD 2o Hypertensive
Nephrosclerosis, Severe anemia of CKD; HPN
Attending Physician:Dra. Mary Dawn Nablo
Date of Admission:February 22, 2014
Discharged: February 23, 2014

History:
Day prior to admission, patient noted chest pain associated with chest pain
tithening. No consult done, no medication taken. Pain relieved temporarily with rest.

Day of consult, increase in intensity of chest pain, patient brought to a clinic and
labs taken. Patient advised admission

Course in the Ward:

Day 1: Patient was admitted to ICU; Patient was intubated at ER and attached to
mechanical ventilator in ICU

Diagnostics:
CBC, UA, Na, K, BUN, Creatinine, CPKMB, Troponine I, ECG 12-Lead, RBS

Medications:
1. Trimethazidine (Vastarel) 35mg tab OD
2. Omeprazole 40 mg IV OD
3. Atorvastatin 80mg tab ODHS
 4. Demerol 75 mg tab for chest pain

Additional Meds:
1. Kalimate 1 sachet in glass of water
2. NaHCO3 650 mg tab TID
3. Levophed drip due to hypotensive episodes
4. Atropine 1 mg/amp
5. D50-50 vial
6. Dopamine drip

Patient had V-Tach episodes. Cardioversion with 300- 360 J. Patient had 2 episodes of
cardiac arrest, due Amiodarone 150 mg IV. Cardiac Arrest with 3 episodes epinephrine
and CPR given. Patient signed a DNR form. Patient expired.