Monina Eula Cheng

GENERAL DATA G. Q. 35 years old male Roman Catholic Filipino Married taxi driver DOA:4/17/10CC: chest

heaviness

HISTORY OF PRESENT ILLNESS

CONSULT

REVIEW OF SYSTEMS (-) sweats, (-) insomia, (-)anxiety, (-)interpersonal relationship

difficulties (-) color changes, (-) rash, (-) photosensitivity, (-) changes in hair/

nails/skin, (-) itchiness (-) blurring of vision, (-)tinnitus, (-)discharge, (-)epistaxis,

(-)discharge , (-)bleeding gums, (-) throat soreness (-) hemoptysis, (-)chest pain, (-)cough (-)nausea, (-)vomiting, (-) hematemesis, (-) melena, (-) hematochezia, (-) dysphagia,(-)epigastric pain,(-)heartburn (-) heat/cold intolerance, (-)polyphagia, (-)polydipsia (-) polyuria (-) muscle pain, (-) joint pain, (-) varicosities, (-)claudication (-) dysuria, (-)flank pain, (-)frequency,(-)hesitancy,(-)urgency (-)headache, (-) seizures (-) easy bruisability

PERSONAL & SOCIAL HISTORYSmoker( 9 pack years)Occasional alcoholic beverage drinkerDenies illicit drug use

Diet: Mixed diet (vegetables, fruits, meat)Taxi driver

PAST MEDICAL HISTORYNo HPN No DM, No Asthma, no PTB, No

allergiesNo operations

FAMILY HISTORY

(-) asthma(-) allergy(-)PTB(+) HPN and heart disease– sister(-) DM(-) Cancer

PHYSICAL EXAMINATION• GENERAL SURVEY: conscious, coherent, oriented

to 3 spheres, ambulates with assisstance, in cardiac distress

• BP 90/60 mmHg PR 85/min RR 22/min Temp 36.5C• SKIN: warm, moist, no active dermatoses• HEENT: pink palpebral conjunctivae, anicteric

sclerae, no nasoaural discharge, moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged

• NECK: no palpable cervical lymph nodes, supple neck, thyroid not enlarged, no other palpable masses

PHYSICAL EXAMINATION• CHEST: symmetrical chest expansion, no

retraction, clear breath sounds• HEART: adynamic precordium, regular rhythm,

apex beat at 5th LICS MCL, no mumurs• ABDOMEN: flat, normoactive bowel sounds, soft,

non-tender, no masses palpated• EXTREMITIES: no cyanosis, no edema, pulses full

and equal, no limitation in ROM

NEUROLOGIC EXAMINATION:Mental Status: Conscious, coherent, oriented to

three spheresCranial nerves: pupils 2-3 mm ERTL, EOMs full

and equal, V1V2V3 intact, can raise eyebrows,can smile, frown, puff cheeks, can close eyes against resistance, no facial symmetry, gross hearing intact, can shrug shoulder against resistance, can swallow, tongue midline on protrusion

Motor: no tremors, no muscle fasciculations, MMT: 5/5 on all extremities

Cerebellar: Can do APST, finger-to-nose test; no gait abnormalities

DTR’s: ++ on all extremitiesSensory: No sensory deficitNo BabinskiNo nuchal rigidity, Brudzinski sign, Kernig’s sign

ASSESSMENT

ASHD, CAD, r/o ACS

Please admit patient at ICU under the service of Dr. Purino Diet: 1800kcal/day: 60% CHO, 15% CHON, 25% fats, <2gNa,

<200mg cholesterol divided into 3 meals and 2 snacks Monitor VS q1 and record Monitor I & O accurately q8h and record Hook to cardiac monitor and pulse oximeter Insert Foley catheter and hook to hospice bag IVF: PNSS 1 L to run at 30gtts/min Request for:

CBC with plt 12LECG Trop I CXRay Na, K BUN, Crea, SGPT Lipid Profile FBS 2D echo with doppler and CS

Therapeutics Start ASA 80 mg/tab, 1 tab OD Clopidogrel 75 mg/tab, 1 tab OD Metoprolol 50 mg/tab, 1 tab OD – hold for now Atorvastatin 80mg/tab, 1 tab ODHS Lactulose 30cc ODHS

Inform AMD of this admission Inform MROD/MIOD as well Admitting history c/o IIC Database c/o CIC Refer accordingly