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    The document describes an 80-year-old male patient who presented to the emergency room with chest pain and shortness of breath and was subsequently admitted to the male medicine ward. His initial workup found elevated blood pressure, abnormal neurological findings including slurred speech and right-sided weakness, and laboratory results indicative of a cardiac event. He was started on medications and monitoring to manage his condition and stabilize his vital signs.

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    Flow Chart

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    nod_nod
    92 views3 pages
    The document describes an 80-year-old male patient who presented to the emergency room with chest pain and shortness of breath and was subsequently admitted to the male medicine ward. His initial workup found elevated blood pressure, abnormal neurological findings including slurred speech and right-sided weakness, and laboratory results indicative of a cardiac event. He was started on medications and monitoring to manage his condition and stabilize his vital signs.

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    The document describes an 80-year-old male patient who presented to the emergency room with chest pain and shortness of breath and was subsequently admitted to the male medicine ward. His initial workup found elevated blood pressure, abnormal neurological findings including slurred speech and right-sided weakness, and laboratory results indicative of a cardiac event. He was started on medications and monitoring to manage his condition and stabilize his vital signs.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    92 views3 pages

    Flow Chart

    Uploaded by

    nod_nod
    The document describes an 80-year-old male patient who presented to the emergency room with chest pain and shortness of breath and was subsequently admitted to the male medicine ward. His initial workup found elevated blood pressure, abnormal neurological findings including slurred speech and right-sided weakness, and laboratory results indicative of a cardiac event. He was started on medications and monitoring to manage his condition and stabilize his vital signs.

    Copyright:

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    of 3

    PAST HISTORY: PRESENT HISTORY:

    The client already had mumps but doesn’t have chicken The symptoms were started on the day prior to admission (July
    pox and measles during childhood and he does receive all 5, 2010) at around 3:30 AM at Emergency Room of Pasig General
    immunizations during his childhood according to him. He Hospital (PCGH). Client X stated that he was lying on bed at that time
    doesn’t have any food, drug or environmental allergy. he felt with a difficulty of breathing.
    As stated by the client, he doesn’t experience any EMERGENCY ROOM: 07-05-10 (3:30 am) The doctor advised him to be admitted in the Male
    accidents in the past and this is the first time he was brought Admitted a 80 y/o married male Filipino client Medicine Ward (MMW) because of his condition. He was transferred
    into the hospital. Every time he had his flu it only last for a CC: CHEST PAIN with shortness of breath to MMW at exactly ________. At that time, his speech became slurry.
    maximum of 4 days. And his starting to have a right body weakness.

    Secured consent for admission


    ASSESSMENT FINDINGS

    BP: 200/110 bpm GCS 11 (EMV) Conscious: (+) DOB Chest pain Slurred speech Slightly
    RR: 28 Weakness of right restless
    PR: 89 side of the body
    TEMP: 37 C
    I&O: >300 cc
    BM: (-)

    NDX: Altered Cerebral Tissue Perfusion

    TREATMENT AND MANGEMENT

    MEDICATIONS: LABORATORIES: Monitor VS Hook O2 via Shift to NPO CBR w/o BRP CBG Hook IVF PNSS 1L x
    1. Citicholine 1gm CBC-PC, PT, PTT, 12Lead q1 NC temporarily KVO
    TIV ECG, CXR, Cranial CT 3-4 Lpm
    2. Omeprazole scan, FBS, Lipid Profile,
    mannitol 150 cc IV Na;K, Creatinine, BUN,
    q6 Urea, SGPT, SGOT, UA LABORATORY RESULTS: CBG result:
    3. Mannitol 150 cc 145 mg/dL
    TIV CBC-PC, Na;K, Creatinine,

    , BUN, PT, PTT, ECG

    Referral to Male Medicine Ward


    ADMITTING DIAGNOSIS: MALE MEDICINE WARD: July 05, 2010 (10:30 am)
    ACS, CVA, infract, HPN Transfer via stretcher

    Please refer under service of Dra. Duro

    ASSESMENT FINDINGS

    (-) DOB BP: 140/70 bpm GCS 12 (EMV) Conscious: Slurred Speech Slightly
    RR: 23 Weakness of right restless
    PR: 85 side of the body
    TEMP: 37 C
    I&O: >300 cc
    BM: 1x

    TREATMENT AND MANGEMENT

    MEDICATIONS: LABORATORIES: Monitor VS Hook O2 via Shift to LSLF MHBR For CBG Hook IVF PNSS 1L
    1. Citicholine 1gm TIV q 12 Still for Trop I and I&O q4 NC & SD with x KVO at 900 cc
    2. Omeprazole 20g/tab OD Follow up CXR, Cranial CT 2-3 Lpm SAP level
    3. ISMN tab OD scan, CP-KMB, FBS, Lipid Positioned
    4. Amlodipine 10g.tab OD Profile, SGPT, SGOT, to MHBR
    5. Lactulose 30cc HS Urinalysis, HDL, LDL CBG result:
    6. Clopidogrel 75g/tab OD 128 mg/dL
    7. Trimetazidine 35g.tab Hooked and Instructed to Keep patent and
    BID regulated have LSLF & SD regulated
    BP: 130/80
    RR: 20
    PR: 80
    TEMP: 36.5 C
    Given as Followed up, I&O: >350 cc
    ordered coordinated BM: (-)
    with laboratory
    MALE MEDICINE WARD: July 06, 2010

    ASSESMENT FINDINGS

    (-) DOB BP: 130/80 bpm GCS 12 (EMV) Conscious: Slurred Speech (-) restlessness
    RR: 19 Weakness of right
    PR: 81 side of the body
    TEMP: 36.8 C
    I&O: >350 cc
    BM: (-)

    TREATMENT AND MANGEMENT

    MEDICATIONS: LABORATORIES: Monitor VS Hook O2 via Shift to LSLF MHBR For CBG Hook IVF PNSS 1L
    1. Citicholine 1gm TIV q 12 Still for Trop I and I&O q4 NC & SD with x KVO at 900 cc
    2. Omeprazole 20g/tab OD Follow up CXR, Cranial CT 2-3 Lpm SAP level
    3. ISMN tab OD scan, CP-KMB, FBS, Lipid Positioned
    4. Amlodipine 10g.tab OD Profile, SGPT, SGOT, to MHBR
    5. Lactulose 30cc HS Urinalysis, HDL, LDL CBG result:
    6. Clopidogrel 75g/tab OD Hooked and Instructed to
    110 mg/dL
    7. Trimetazidine 35g.tab regulated have LSLF & SD Keep patent and
    BID regulated

    BP: 130/70
    RR: 18
    PR: 85
    Given as TEMP: 36.9 C
    ordered I&O: >320 cc
    BM: (-) CT SCAN RESULTS
    IMPRESSION:
    1. Physiologic calcification versus
    LABORATORY RESULTS: punctuate hemorrhage? Hemorrhagic?
    Right globus palllidus
    Still for Trop I 2. Age related cerebro volume loss
    Follow up CXR, Cranial CT scan, CP-KMB, FBS, 3. Atherosclerotic left vertebral artery
    Lipid Profile, SGPT, SGOT, Urinalysis, HDL, LDL

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