University of Santo Tomas

Faculty of Medicine and Surgery

Department of Internal Medicine
Clinical Division
Room/Bed MICU B (+) NSAID use (etoricoxib)
Hospital Number 20-120000263043 Herbal medications: MX3 (2018)
Admission Number 20B00358
Patient LLORENTE, MA. ELENA PADERES Family History
Age/Sex 78/F (-) Hypertension
Date of Birth 07/04/1942 (-) Stroke
(-) DM
Civil Status Widowed
(-) Asthma
Nationality/ Citizenship Filipino
(-) TB
Home Address 1816 RIZAL AVE STA. CRUZ MANILA
(-) Kidney disease
Occupation unemployed (-) Goiter
Religion Roman Catholic
Date of Admission 02/28/20 Current Medications:
Time of Admission 01:50 AM Amlodipine 5mg/tab OD
Informant Patient
Reliability (%) Good Physical Examination on Admission
Attending Physician Dr. C. Mendoza General Survey: awake, follows command, in respiratory distress
Resident/s-in-Charge Dr.Taytayon/Caylao VS: BP 150/90, PR 95, RR 24, T 36.5˚C, O2 sat 98%
Anthropometrics: Ht: 156cm Wt: 49kg
Skin: warm, dry skin, good turgor, (+) pallor, no jaundice, no facies
Chief Complaint Dyspnea
Head: no abnormal facies, normal hair distribution
Eyes: pale palpebral conjunctiva, anicteric sclerae, pupils 2-3mm ERTL
Ears: no tragal tenderness, no aural discharge
History of Present Illness:
Nose: septum midline, no tenderness, no nasal discharge
One week prior to admission, patient had tachypnea accompanied by alteration in sleep Throat: dry lips, tonsils not enlarged, non-hyperemic posterior pharyngeal wall
wake cycle. Patient also had occasional aspiration during feedings. No chest pain, abdominal Neck: trachea midline, no palpable anterior neck mass, (-) thyroid enlargement, (-) cervical
pain, cyanosis, headache, loss of consciousness, trauma noted. lymphadenopathy, (-) limitation of movement
Respiratory: symmetrical chest expansion, (+) supraclavicular, intercostal retractions, equal vocal and
One day prior to admission (2/27/20 1am), patient complained of dyspnea accompanied by tactile fremiti, resonant on percussion, (+) bibasal crackles
cyanosis of the lips and diaphoresis. No chest pain, numbness noted. Progression of Cardiovascular: adynamic precordium, JVP 5.2 cm at 45 degrees (-)heave, (-) lifts (-) thrills, apex beat at the
symptoms prompted consult at the UST ERCD hence subsequent admission. 6th LICS MCL, normal heart sounds, (-) murmurs
Gastrointestinal: flabby, no visible abdominal pulsation, normoactive bowel sounds, tympanitic on all
Review of Systems quadrants, and (-) direct/rebound tenderness
General Survey:(-) fever, (-) undocumented weight loss, (-) loss of appetite Genitourinary: (-) CVA tenderness
Extremities: pulses full and equal, no bipedal edema
Cutaneous: (+) pallor, (-) jaundice, (-) rashes
Eye: (-) eye pain, (-) blurring of vision, (-) doubling of vision
Neurological Exam
Ear: (-) hearing loss/deafness, (-) discharge, (-) ear pain, (-) tinnitus GCS 12 (E4V2M6): Oriented to time, place and person
Nose: (-) discharge, (-) anosmia Cranial Nerves:
Mouth: (-) bleeding gums, (-) soreness of tongue, (-) fissures, (-) oral ulcers CNI – not assessed
Throat: (-) sore throat, (-) voice change/hoarseness, (-) itchiness CN II – pupils 2-3mm ERTL
Neck: (-) neck stiffness, (-) dysphagia, (-) odynophagia, (-) limitation of motion, (-) mass CN III, IV, VI – EOMs full and intact
Respiratory: See HPI CN V – can clench teeth, no sensory deficit
Cardiology: See HPI CN VII – (-) facial asymmetry, can smile, can frown, can puff cheeks, raise eyebrows, wrinkle forehead
Vascular: (-) varices CN VIII – gross hearing intact
Gastrointestinal: (-) diarrhea, (-) constipation, (-) melena, (-) hematochezia (-) indigestion CN IX,X – uvula midline
Genitourinary: (-) dysuria, (-) frequency, (-) nocturia, (-) hematuria (+) incontinence CN XI – can shrug both shoulders and turn head against resistance
CN XII – tongue protrusion midline
Musculoskeletal: (+) hip pain, (-) edema, (-) joint pains, (-) myalgia
Motor: 3/5 all extremities
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) heat/cold intolerance
Cerebellum: no tremors, no dysdiadochokinesia, no dysmetria
Hematologic: (-) easy bruisability, (-) petechiae, (-) epistaxis
Sensory: no sensory deficits
Neurologic: (-) seizure, (-) paralysis, (-) dizziness, (-) loss of consciousness Reflexes: ++ DTRs on all extremities
Psychiatric: (-) anxiety, (-) depression, (-) hallucination, (-) mood change Meningeal: no nuchal rigidity, (-) Kernig’s sign, (-) Brudzinski sign

Initial Assessment:
Past Medical History
ASHD, CAD, NSTEMI, !F, Class IVD, AKI sec to decreased ECV sec to NSTEMI, CRS type 1
Adult illness
probable CKD sec to HTN nephrosclerosis, ARF sec to CAP HR, pulmonary congestion; s/p
(+) CVA (2013)- USTH, 1 week
RAI (1999), CVA (2012)
(+) HTN (2003) undocumented UBP and HBP; on Amlodipine 5mg/tab 1 tab OD
(+) Bedridden sec Trauma (2017)
(+) Arthritis
Plans
(-) DM
Please admit at MICU B under the service of Dr. Yamamoto
(-) Asthma
(-) PTB Diet: 30 kcal/kg/day, 60% CHO, 15% CHON, 25% fats, <2g Na, <7% Sat. Fat, <200 mg
(-) Gout cholesterol divided into 3 meals and 2 snacks
(-) MI Start CBG monitoring.
(-) Previous angina Monitor input and output every shift and record. Include urine output at VS monitoring
(-) HF sheet c/o CCIC
Previous hospitalizations: Hospitalized for CVA (USTH)- 2013 Monitor VS Q1 and record
Previous surgery: None Insert Heplock
Blood transfusion: none Insert indwelling foley catheter
Allergies: none Diagnostics:
 12L ECG
Current Heath Status/ Risk Factors
 Troponin I
(+) smoker: 30 pack years
Non alcoholic beverage drinker  2D echo with doppler studies
Recent antibiotic use: None  KUBP UTZ

1
 University of Santo Tomas
Faculty of Medicine and Surgery
Department of Internal Medicine
Clinical Division
 CBC with platelet
 Na, K, Crea, BUN
 iCa, PO4, Mg
 FT3, FT4, TSH
 AST, ALT
 Lipid Profile
 Urinalysis
 Chest X-ray (AP sitting)
 Troponin I
 Pelvic and lumbo-sacral X-ray
Therapeutics
 Aspirin 80mg/tab 4 tablets now then 1 tablet once a day
 Clopidogrel 75mg/tabs 4 tablets now then 1 tablet once day
 Enoxaparin 0.4ml/SC now then once a day
 Atorvastatin 80mg/tab 1 tab now then once a day
 Lactulose 30ml ODHS, hold is BM >3x/day
Complete bed rest and Avoid straining
For ‘E’ intubation; ET size 7.5 level 20
Refer to PULMO service for co-management
Suction secretions as needed
Refer NEPHRO for co-management
Please accomplish admitting history, MPL, LFS c/o CCIC within 24 hours of admission.
Please inform CFOD Yamamoto/MROD Taytayon and MROD Caylao of this admission.
Please transfuse 1 unit PRBC properly typed and crossmatched to run for 6 hours
Pre BT meds: Paracetamol 500mg/IV 30 mins prior to BT

PUA,F/REFUERZO/REYES, CA/REYES, CO/RIVERA

Clinical Clerks-in-Charge

DR.TAYTAYON/DR. CAYLAO
Residents-in-Charge