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ADMISSION CONFERENCE

ADMISSION CONFERENCE. General Data. Name: L.D. Age & Gender : 68/Male Chief Complaint: Difficulty of Breathing. History of Present Illness. 45 years PTA. Known case of Bronchial Asthma since 1964 (patient was 23 years old) Was prescribed: unrecalled inhaler PRN

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ADMISSION CONFERENCE

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  1. ADMISSION CONFERENCE

  2. General Data Name: L.D. Age & Gender: 68/Male Chief Complaint: Difficulty of Breathing

  3. History of Present Illness 45 years PTA • Known case of Bronchial Asthma since 1964 (patient was 23 years old) • Was prescribed: • unrecalled inhaler PRN • Theophylline (Asmasolon) 1tab BID, not compliant • Asthma attacks • occurred once every month • precipitated by hot weather and exposure to smoke and dust • relieved with use of inhaler medications • no report of nocturnal awakenings

  4. History of Present Illness • Asthma attacks • occurred 2-3x/week • precipitated by hot weather and strenuous exercise • relieved with use of Salbutamolrotacap • (+) nocturnal awakenings, 1-2x/month 20 years PTA

  5. History of Present Illness 2 years PTA • Acute exacerbation after exposure to a significant amount of smoke • severe dyspnea and chest tightness • became unconscious & cyanotic after a few minutes • Bought to DiosdadoMacapagal Hospital • Assessment: Bronchial Asthma, in acute exacerbation and Community Acquired Pneumonia • Unrecalled laboratory examinations and medications given • No immunization was offered

  6. History of Present Illness 2 days PTA ↑severity of dyspnea, neither relieved by Salbutamol inhaler nor by nebulization (+) wheezing, cough, chest tightness, profuse sweating (-) fever & chills, orthopnea, PND, pleuritic chest pain His relatives also noticed that he was getting cyanotic on his extremities and lips Persistence of above symptoms  consult • Dyspnea even at rest, temporarily relieved by Salbutamol inhaler • Productive cough of whitish sputum, (+) wheezing • Prefers to be in sitting position • No consult was done 7 hours PTA ADMISSION

  7. Review of Systems??? (-) wt loss, (+)anorexia, (+)weakness, (-)fatigue, insomnia (-) itchiness, pigmentation, rash, active dermatoses (-) blurring of vision, redness, itchiness, Iacrimation (-) deafness, tinnitus, aural discharge (-) anosmia, epistaxis, sinusitis, nasal discharge (-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion (-) breast masses, discharge, trauma (+) dyspnea, (+) cough, (-) hemoptysis, (-) easy fatigability, chest pain, nocturnal dyspnea, palpitation, syncope, edema (-) phlebitis, varicosities, claudication (-) dyshpagia, nausea, (+)vomiting, retching, hematemesis, melena, hematochezia, belching, indigestion, diarrhea, constipation (-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia, urethral (-) joint stiffness, joint pain, muscle pain, cramps (-) heat-cold intolerance, polydipsia, polyphagia, polyuria (-) headache, speech disturbance – change in voice, (-) seizures (-) anxiety, depression, IPR difficulties 

  8. Past Medical History Previous Surgery • Anal Fistula, s/p Fistulectomy, February 2009 Major Adult Illnesses • Hypertension, Stage II, uncontrolled (1990) • Highest BP 190/110, Usual BP 180/90 • Olmesartan 20mg/tab, non-compliant Immunizations: unrecalled Allergies • Aspirin • Unrecalled antibiotics

  9. Family History (+) Hypertension : father (+) Heart disease : father, cause of death (+) DM type II : mother and sister (-) Asthma, PTB, Cancer, Thyroid disorder

  10. Personal and Social History • Mixed diet • Non smoker • Non alcohol beverage drinker • Denies illicit drug use

  11. Physical Examination on Admission General Survey: Conscious, coherent, ambulatory, in respiratory distress, in tripod position, speaks in phrases Vital Signs:BP 190/90mmHg PR 104bpm, regular RR 24cpm, regular T 38oC Height: 5ft Weight: 55kg BMI: Skin: Warm moist skin, no rashes, no jaundice, no active dermatosis Head:Normocephalic, pink palpebral conjunctiva, anicteric sclera, isochoric pupils, midline septum, no alar flaring, no nasoaural discharge, turbinates not congested, no oral ulcers, moist buccal mucosa, nonhyperemic pharyngeal wall, tonsils not enlarged, no aural pits or tags, no tragal tenderness, nonhyperemic EAC, intact TM, AU

  12. Physical Examination on Admission Neck: Supple neck, non prominent SCM, trachea at midline no distended neck veins, no neck mass, no palpable cervical lymph nodes,no carotid bruit, CAP: rapid upstroke, gradual downstroke, JVP: 4.5cm at 45o Chest: Symmetrical chest expansion, no barrel chest, (+) supraclavicular retractions, ↓tactile and vocal fremiti at L hemithorax, dullness on R lung, T5-T7, (+) wheezes and (+) coarse crackles on both lung fields, (+) Egophonyon both lung fields Heart: Adynamicprecordium, apex beat at 5th LICS, MCL, no lifts, no heaves, no thrills, S1 is louder at the apex, S2 louder at the base, (-) S3, (-) murmurs

  13. Physical Examination on Admission Abdomen: Globular, no scars, midline inverted umbilicus, normoactive bowel sounds (9/min), tympanitic all over, liver span = 8cm, Traube’s space not obliterated, (-) CVA tenderness, no direct or rebound tenderness, no masses Extremities: no deformities, no edema, no clubbing, no peripheral or central cyanosis, Pulses: ++ on all extremities

  14. Physical Examination on Admission Neurologic Examination Mental Status: Conscious, coherent, oriented to time, place and person, follows commands Cranial nerves: Olfaction intact, bilateral pupils 2-3mm ERTL, no visual field cuts, EOM’s full and equal, V1V2V3 intact, can raise eyebrows, smile, frown, puff cheeks, intact gross hearing, uvula midline on phonation, (+) gag reflex, can shrug shoulders, can turn head side to side against resistance, tongue midline on protrusion Motor: no atrophy, no fasciculations, no spasticity or rigidity, MMT 5/5 on all extremities Cerebellar: can do APST and FTNT with ease on both upper extremities Sensory: no sensory deficit Reflexes: DTRs ++ on all extremities, (-) Babinski Meningeal signs: (-) nuchalrigidty, (-) Brudzinski, (-) Kernig’s

  15. Assessment • Bronchial Asthma, moderate persistent?, in acute exacerbation • Community Acquired Pneumonia, in patient, non-ICU • Hypertension, Stage 2, poorly controlled

  16. Plans Diagnostic: • CBC • CXR (PA,L) • Serum BUN, Crea • 12 Lead ECG • Serum Na, K • ABG • Sputum Gram Stain Therapeutic: • O2 supplementation (4lpm) • Salbutamol + Ipratropium Bromide (Combivent) nebulization q6h • Hydrocortisone 100mg/IV q8h • Cefuroxime 500mg/tab 1tab BID • Azithromycin 500mg/tab 1 tab OD • Erdosteine 300mg/cap 1 cap BID • Simvastatin 20mg/tab 1tab ODHS • Losartan 50mg/tab 1tab OD • Amlodipine 5mg/tab 1tab OD • Clopidogrel 75mg/tab 1tab OD

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