Diagnosis

T/C unstable angina, CAD, Cardiomegally, old septal wall MI, lateral wall,
functional class 1.

General Health
A case of VC, 61 years of age, RC, a resident of Opol Mis. Or., admitted for the
first time here in NMMC due to chest pain.

Source of information: patient with 70% reliability

HPI:
Four hours PTA, patient had onset of epigastric pain and chest pain, radiating to
back area, negative vomiting, negative nausea, negative LBM, negative fever, negative
rashes, exchange in sensorium, patient immediately sought consult hence this
admission.

Patient History
● Known HPN
● Not known diabetic
● Not known asthmatic
● No known food & drug allergies
● Previously admitted as HPN a year ago given with unrecalled meds. Patient did
not maintain HPN meds.
● Smoker
● Occasional alcoholic beverage drinker
● Unemployed

Family History
● Negative HPN
● Negative DM
● Negative Asthma
● Negative Cancer

Upon Admission
● Negative weight loss
● Negative loss of appetite
● Negative Cough
● Negative Melina
● Negative Orthopnea
● Negative Paroxysmal Nocturnal Dyspnea
● Negative Exertional
● Negative Dyspnea

Vital Signs upon admission

BP – 200/100 mmHg
PR – 82 bpm
 RR – 28 cpm
T – 36.1 °C

Doctor’s Order
February 14, 2011
12:30 am Please admit patient to P2F2 (MTB)
Secure consent to care and management
Diagnosis: T/C unstable angina, CAD, Cardiomegally, old septal wall MI,
lateral wall, functional class 1.
Diet: low salt, low fat with strict aspiration precaution please
IVF – D5W 500cc @ 10cc/hr
Labs:
CBC, platelet count
U/A, BUN, Creatinine
CXA-PAL
ECG 12
Troponin 1
Meds:
Aspirin SD 4 tabs now then 1 tab PC
Clopidogrel 75mg 4 tabs now then 1 tab OD
Captopril 25mg 1 tab SL now then 1 tab q6h
Atorvastatin 40mg 1 tab @ HS
Metoprolol 50mg 1 tab BID
I and O q shift in absolute value
Monitor v/s q2h: record if:
BP > 140/90 mmHg or < 90/60 mmHg
PR > 100 bpm or < 60 bpm
RR > 30 cpm or < 10 cpm
Warn ROD for persistent chest pain and other unsualities
O2 inhalation @ 2L/min via nasal cannula
O2 sat. monitoring q4h, record and refer for O2 sat less than 90%
Refer please
Thank you!

8:30am For repeat ECG 12 Lead with V2

For SGPT determination
For repeat troponin 1
For sputum exam for 3 testing to 11-7 ROD, handle and facilitate sputum
collection
Start Omeprazole 20mg/cap 1 cap BID 30 minutes before meals
Start ISMN 60mg half-tab OD
Thank you!

Lab Exam Results

Troponin 1
Result – 0.4ng/mL Reference: <0.6ng/mL
Urinalysis
Physical properties
Color – Yellow
Clarity – Clear
PH – 7.0
Specific Gravity – 1.015
Chemical Properties
Negative Glucose
Negative Protein
Negative Bilirubin
Sedimentary Microscopic Exam
Pus Cell: WBC: 2-3
RBC: 1-3
Mucus Threads: Few

Blood Chemistry
Result Reference
RDS 104.0 60 – 110%
BUN 12.59 4.6 – 23.4%
K 3.91 3.5 – 5.3 mmol/L
Na 141.98 135 – 148 mmol/L