Transcript 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
– 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
History of Present Illness
20 years
PTA
• Asthma attacks
– occurred 2-3x/week
– precipitated by hot weather and
strenuous exercise
– relieved with use of Salbutamol
rotacap
– (+) nocturnal awakenings,
1-2x/month
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 Diosdado Macapagal Hospital
• Assessment: Bronchial Asthma, in acute
exacerbation and Community Acquired
Pneumonia
• Unrecalled laboratory examinations and
medications given
• No immunization was offered
History of Present Illness
2 days PTA
• 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
• ↑severity of dyspnea, neither relieved by
7 hours PTA
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
ADMISSION • Persistence of above symptoms  consult
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
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
Family History
(+) Hypertension : father
(+) Heart disease : father, cause of death
(+) DM type II : mother and sister
(-) Asthma, PTB, Cancer, Thyroid disorder
Personal and Social History
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Mixed diet
Non smoker
Non alcohol beverage drinker
Denies illicit drug use
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
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, (+) Egophony on both lung
fields
Heart: Adynamic precordium, 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
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
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: (-) nuchal rigidty, (-) Brudzinski, (-) Kernig’s
Assessment
• Bronchial Asthma, moderate persistent?, in acute
exacerbation
• Community Acquired Pneumonia, in patient, non-ICU
• Hypertension, Stage 2, poorly controlled
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