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Intern’s Audit

Intern’s Audit. Monina Eula Cheng. GENERAL DATA. G. Q . 35 years old male Roman Catholic Filipino Married taxi driver DOA:4/17/10 CC: chest heaviness. HISTORY OF PRESENT ILLNESS. CONSULT. REVIEW OF SYSTEMS.

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Intern’s Audit

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  1. Intern’s Audit Monina Eula Cheng

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

  3. HISTORY OF PRESENT ILLNESS CONSULT

  4. 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

  5. PERSONAL & SOCIAL HISTORY • Smoker( 9 pack years) • Occasional alcoholic beverage drinker • Denies illicit drug use • Diet: Mixed diet (vegetables, fruits, meat) • Taxi driver

  6. PAST MEDICAL HISTORY • No HPN No DM, No Asthma, no PTB, No allergies • No operations

  7. FAMILYHISTORY • (-) asthma • (-) allergy • (-)PTB • (+) HPN and heart disease– sister • (-) DM • (-) Cancer

  8. 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 36.5C • 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

  9. 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

  10. NEUROLOGIC EXAMINATION: • Mental Status: Conscious, coherent, oriented to three spheres • Cranial 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 extremities • Sensory: No sensory deficit • No Babinski • No nuchal rigidity, Brudzinski sign, Kernig’s sign

  11. ASSESSMENT • ASHD, CAD, r/o ACS

  12. 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

  13. 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

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