Admission Conference

Ernesto V. Ignacio Jr.

• FEF
• 60 y.o / Male
• Married
• Unemployed
• Valenzuela City
 Patient would experience chest pain described as “heaviness” graded 7/10 that would radiate to the
1 back and last for 30 seconds which would be relieved by rest. No headache, dizziness, nausea,
month vomiting and dyspnea were noted. No medications were taken. No consult was done
PTA

Interval history showed frequency of chest pain that would still radiate to the back and increase in
severity. Still no headache, dizziness, nausea, vomiting and dyspnea were noted. No medications were
taken. No consult was done.

17 hrs Patient experienced chest pain while cleaning which he described as “nadaganan” graded 10/10 that
PTA would radiate to the back and was not relieved by rest. Patient then consulted at the ER in Medical
Center-Valenzuela where Troponin I was done and resulted to be elevated 3.69 ng/mL. The patient
was given Isosorbide dinitrate 5mg sublingual, 4 tablets of aspirin, 4 tablets of clopidogrel and
Tramadol IV. The physician in Medical Center-Valenzuela advised to consult a tertiary hospital that
would better accommodate the patient’s treatment hence admission
Past Medical History
(-) HTN
(-) DM
(+) PTB – completed 6 months of treatment (2005)
(-) CA
(-) Thyroid disorders
(-) Asthma
(-) Arthritis

Previous Hospitalization: 2011 – Motor Vehicle Accident

Family History
(+) MI – father and brother
(-) stroke
(-) DM
(+) Cancer – Lung Cancer- brother
Personal and Social History
Previous smoker – 44 pack-years
Occassional alcoholic beverage drinker
Denies illicit drug use
No known allergy to food or drugs
Diet consists of rice fish and vegetables with occasional meat intake
Review of Systems
General: conscious, coherent, not in distress (-) fever (-) loss of appetite
Skin: (-) hair loss (-) pruritus, (-) pallor (-) jaundice, (-) petechiae
Eyes: (-) change in vision, (-) eye discharge
HEENT: (-) headache, (-) ear discharge, (-) tinnitus, (-) vertigo, (-)
epistaxis, (-) change in sense of smell, (-) colds, (-) sinus pain, (-) sore
throat, (-) gum bleeding
Respiratory: (-) colds, (-) cough
Cardiovascular: see HPI
Review of Systems
Gastrointestinal: (-) pain, (-) constipation, (-) diarrhea, (-) hematemesis, (-)
hematochezia (-) vomiting
Genitourinary: (-) dysuria, (-) hematuria, (-) frequency, (-) urgency, (-)
nocturia, (-) hesitancy, (+) weak urinary stream, (+) dribbling
Hematologic : (-) pallor, (-) gum bleeding, (-) easy bruisability
Endocrine (-) polyuria, (-) polydipsia, (-) polyphagia, (-) cold intolerance, (-)
tremors
Nervous: (-) headache, (-) seizures
Musculoskeletal: (-) swelling (-) knee pains (-) myalgia
Behavior/Psychiatric: (-) behavioral changes, (-) restlessness
Physical Examination
General: Conscious, coherent, not in cardiorespiratory distress, oriented to 3
spheres
BP: 150/90 PR: 82 bpm RR: 17 cpm O2 98% Temp: 36.2°C Wt: 65 kg Ht: 172.7
cm
Skin: warm, not dry, no pallor, no jaundice
Head: no facial asymmetry
Eyes: pink palpebral conjunctiva, anicteric sclera, isocoric pupils 2-3 mm ERTL
Ear: normal set ears, no aural discharge, no tragal tenderness
Nose: nasal septum midline, no nasal discharge, non-congested turbinates
Throat: non-hyperemic, no enlarged tonsils
Mouth: moist lips and buccal mucosa, no oral ulcers, non-hyperemic posterior
pharyngeal wall, tonsils not enlarged
Physical Examination
Repiratory: symmetrical chest expansion, equal vocal and tactile
fremiti, resonant on all lung fields, normal breath sounds
Cardiovascular: adynamic precordium, no heaves/thrills/lifts, rhythm
regular, apex beat at 6th LICS AAL, loud s1 followed by soft s2 at the
apex, soft s1 followed by loud s2 at the base, no murmurs
Gastrointestinal: flat, flabby, normoactive bowel sounds, tympanitic on
percussion, no direct or rebound tenderness on all quadrants.
Genitourinary: (-) CVA tenderness
Extremities: (-) bipedal edema, (-) deformities, (-) cyanosis, pulses full
& equal
 Subjective Objective
60, Male Vital signs: BP 150/90 mmHg; PR 92 bpm, regular;
RR 17 cpm; T 36.20C;

(+) chest pain No sensory deficit

BMI=23
Family History : (+) MI – father and brother

(-) HTN

(-) DM

(-) Thyroid dse

NYHA Functional Classification
Stage Description
I Symptoms occur with greater than ordinary
physical activity
II Symptoms occur with ordinary physical
activity

III Symptoms occur with less than ordinary

physical activity

IV Symptoms occur may be present even at rest

ACC/AHA Stages of Heart Failure
Stage Description
A At high risk for HF but without structural
heart disease or HF symptoms
B Structural heart dse but without signs or
symptoms of HF
C Structural heart disease with previous or
current symptoms of HF
D Refractory HF requiring specialized
interventions
Impression

• ASHD, CAD, NSTEMI, not in failure class IIB

Plans
• Diet 30 kcal/kg/day 60% CHO, 25% fats, 15% CHON, <4g Na, <200g
cholesterol, <7% saturated fats, divided into 3 meals and 2 snacks.
• Monitor I & O q shift and record
• Monitor VS every hour and record
• Ideally for ICU admission, however, due to financial constraints, opted
to be admitted at a regular ward
Diagnostics
• CBC with platelet
• BUN, Na, K, Crea
• Urinalysis
• 12L ECG
• CXR
• FBS, lipid profile
• 2D Echo with Doppler
• Troponin I
• Ca, Mg
Therapeutics
• Aspirin 80mg/tab 4 tabs now then 1 tab OD
• Clopidogrel 75mg/tab 4 tabs now then 1 tab OD
• Atorvastatin 80mg/tab 1 tablet at bedtime
• Enoxaparin 0.6 cc BID
• Trimetazidine 35mg/tab 1 tab BID (every 12 hours)
• Bisoprolol 2.5 mg/tab 1 tab OD
• Omeprazole 40 mg/tab (Risek) 1 tab, 30 minutes pre-breakfast
• Lactulose 30 cc OD before bedtime