Ateneo School of Medicine and Public Health

Year Level 8: Clerkship

Patient Database
Patient Name: E, E
Age: 55
Birthdate:
Room #:
Chief Complaint: Chest pain
Date of Admission: 2016
History of Present Illness:
Patient was apparently well, until around 5:30am in the morning where he was awakened from his
sleep due to sudden onset of severe chest pain, 9/10, characterized as heaviness, associated with
diaphoresis and difficulty of breathing. No medications were taken.
The persistence and non-relief of the chest pain prompted ER consult and subsequent admission.
Past Medical History
Medication List
[ - ] Hypertension [ - ]Diabetes Mellitus [ - ]
None
Bronchial Asthma
[ + ] Other Illnesses: Worked up for adrenal
nodules
[ - ] Allergies: None
[ - ] Previous Surgeries: None
[ - ] Previous Hospitalizations None
[ - ] Immunizations None
Ob/Gyne
Menarche:
Coitarche:
Menopause:
G____P____(
)

N/
A

History
Interval:
Duration:
Amount:
Symptoms:

Personal-Social History
Occupation: Manager
Smoking: 2 pack years
Alcohol: Occasional alcoholic beverage drinker
Drugs/ Other Vices: Denies
Review of Systems

General: No Weight loss or gain, Fatigue,

Fever, weakness
HEENT: No headache, deafness, discharge,
blurring, hoarseness
Cardiovascular: No chest pain, palpitations,
orthopnea
Pulmonary: No cough, sputum, hemoptysis,
DOB
Gastrointestinal: No nausea, change in bowel,
bleeding, pain
Genitourinary: No dysuria, frequency,
hematuria, urgency

BP:139/95
Temp:36.8

Endocrine: No polyuria, polydipsia, heat/cold

intolerance
Hematologic: No ease of bruising or bleeding,
jaundice
Neurologic: No dizziness, seizures, weakness,
numbness
Psychiatric: No nervousness, depression,
memory loss
Musculoskeletal: No joint/back/muscle pain,
no swelling
Dermatologic: No rashes, lumps, itching,
dryness.

Physical Examination Findings on Initial Examination

Vital Signs
Anthropometrics
PR:88
RR:19
Ht (cm): 170
Wt (kg):77
BMI: 26.85
Pain Scale:
8/10
Weight Classification: Obese
IBW:
type I

General Appearance: The patient is in Cardio-respiratory distress. He is alert and oriented to person,
place and time. In pain.
Chest/ Lungs: Symmetrical chest expansion, normal resonant percussion, clear breath sounds.
Cardiovascular: Adynamic precordium, no lifts or heaves, PMI in the 5th ICS MCL, S1>S2 at the apex,
S2>S1 at the base, no S3 or S4, no murmurs.
Abdomen: Flabby, no scars, normoactive bowel sounds, no tenderness on light and deep palpation, no
masses, no guarding.
Genitourinary: No CVA tenderness
Musculoskeletal: No cyanosis or clubbing, full ROM on all extremities, no swelling or tenderness on
muscles and joints
Skin: No lesions, good turgor

Ateneo School of Medicine and Public Health

Year Level 8: Clerkship
Neurologic: GCS 14, Cranial nerves intact, normal muscle tone. 5/5 strength in all extremities, normal
light touch, position sense, vibration and sharp. Normal deep tendon reflexes, no Babinski. Normal gait and
balance, no dysmetria, no dysdiadochokinesia.

Subjective Salient Features (History)

55/M, CC: Chest pain
No known co-morbidities
Had sudden onset of severe chest heaviness with
diaphoresis and difficulty of breathing
Previously worked-up for adrenal nodules
Family history of hypertension, DM, MI and stroke
Obese type I
2 pack years smoker and occasional alcoholic
beverage drinker

Objective Salient Features (PE + Labs)

Awake, alert, coherent, in cardiorespiratory
distress and noticeably in pain
BP 139/95, PR 88, RR 19, T 36.8C and PX of 6/10
Adynamic precordium, normal rate and regular
rhythm, distinct S1 and S2, no S3
Equal chest expansion and clear breath sounds
Flabby, soft, non-tender abdomen

Initial Assessment:
ACS
Differential Diagnoses
1. GERD
2. Costochondritis
3. Anxiety attacks
4.CAP
5.
Complete Diagnosis on Discharge
2 V CAD
ST-elevation MI, anteroseptal wall
Impaired fasting glucose, pre-diabetes
Home Medications
1.Aspirin 50/tab
2.Clopidogrel 75mg/tab
3.Pantoprazole 40mg/tab
4.Atorvastatin 80mg/tab
5.Cardevilol 6.25mg/tab
6.Metformin 500 mg/tab
7.trimetadine 30mg/tab

Completed by:
_M.M__________________________
Clerk-In-Charge / Date / Time
Checked by:

Screening/ Confirmatory test for Differential

Diagnosis
1.ECG
2.Chest X-ray
3.Omeprazole test
4.
5.

Home Instructions
1 tab OD (12nn)
1 tab OD
1 tab OD
1 tab OD
1 tab BID hold for SBP <110, HR <11
1 tab OD hold if with diarrhea
1-tab BID

Ateneo School of Medicine and Public Health

Year Level 8: Clerkship

________________________________________________________
IM Resident-In-Charge / Date / Time

Ateneo School of Medicine and Public Health

Year Level 8: Clerkship

Drug Database
Generic Name:
Aspirin
Drug Class:
Anticoagulant, antiplatelets, fibrinolytics and
NSAID
Drug Structure:

Brand Names:
Aspilet
Dosage Forms:
Oral tablet
Drug Appearance:

Indications: Prophylactic treatment of thromboembolic disorders, MI, transient ischemic attacks (TIA) &
stroke. Secondary prevention of cerebrovascular events in patients w/ DM esp. those w/ history of MI, TIA
or minor stroke, angina & those w/ additional risk factors: HTN, smoking, dyslipidemia & family history of
CV disease; reinfarction in patients w/ previous MI; restenosis of CABG; thrombosis of arteriovenous shunts
in patients undergoing hemodialysis. Revascularization procedures. Pregnancy-induced HTN
Dosing: Suspected acute MI Initial dose: 160 mg. Maintenance dose: 160 mg/day continued for 30 days
post-MI. Prevention of recurrent MI, unstable angina pectoris & chronic stable angina pectoris, primary &
secondary prevention of CV events in patients w/ DM 75-325 mg once daily
Adverse Effects:
Fever, hypothermia, thirst. Dysrhythmias, hypotension, tachycardia. Agitation, cerebral edema, coma,
confusion, dizziness, headache, subdural or intracranial hemorrhage, lethargy, seizures. Dehydration,
hyperkalemia, metabolic acidosis, resp alkalosis, dyspepsia, GI bleeding, ulceration & perforation, nausea,
vomiting, transient hepatic enzyme elevations, hepatitis, Reye's syndrome, pancreatitis. Prolongation of
prothrombin time, disseminated intravascular coagulation, coagulopathy, thrombocytopenia. Acute
anaphylaxis, angioedema, asthma, bronchospasm, laryngeal edema, urticaria. Hearing loss, tinnitus.
Hyperpnea, pulmonary edema, tachypnea. Interstitial nephritis, papillary necrosis, proteinuria, renal
insufficiency & failure. Rhabdomyolysis. Hypo/hyperglycemia.

Drug Interactions: Anticoagulants, acetazolamide, anticonvulsants, ACE inhibitors, -blockers,

diuretics, methotrexate, NSAIDs, oral hypoglycemics, uricosuric agents.
Mechanism of Action
Half Life
Antithrombotic activity of aspirin is due to its
15-20mins
inhibitory effect on platelets which is mediated via
irreversible acetylation of platelet cyclooxygenase
with subsequent blockade of platelet thromboxane
synthesis. The inhibitory effect of aspirin on platelet
thromboxane production persists for the lifespan of
the platelet, around 7-10 days

Metabolism/ Excretion
1% is excreted as unhydrolyzed in the urine
the remainder is excreted as salicylates and its
metabolites.
Bioavailability:
68%

Onset of Action
4-6 hours

Metabolites:
salicylic acid, its acyl and phenolic
glucuronides, salicyluric acid, its phenolic
glucuronide and gentisic acid.
Patient Correlation
Post MI patients are given aspirin to prevent stroke episodes especially so that the patient has
diabetes

Completed by:

Ateneo School of Medicine and Public Health

Year Level 8: Clerkship

M.M. ________________
Clerk-In-Charge / Date / Time
Checked by:

__________________________________________
______________
IM Resident-In-Charge / Date / Time

Problem
1/22/16
1.) Chest
heaviness

2.) Loose stools

1/23/16
1.) Chest
heaviness

2.) Diarrhea

Ateneo School of Medicine and Public Health

Year Level 8: Clerkship
S/O
A
>Awake, comfortable and
afebrile
>Chest heaviness resolved
>No dyspnea, no syncope
episodes
>Conscious, coherent, oriented
to three spheres
>BP 110/80, HR 80, RR 20, T 36
>Adynamic precordium, distinct
heart sounds, no murmurs
>Symmetric chest expansion,
clear breath sounds
>Full and equal pulses, no
cyanosis

Acute ST-elevated
myocardial infarction
s/p stenting of Left
anterior descending
artery

>Stools are watery, non-bloody,

non- mucoid, after intake of
lactulose
>Flabby, hyperactive bowel
sounds, soft, non-tender
abdomen.

Lactulose induced
diarrhea

>Awake, comfortable and

afebrile
>No chest pain
>No dyspnea, no syncope
episodes
>Conscious, coherent, oriented
to three spheres
>BP 110/70-80, HR 80-87, RR
19, T 36
>Adynamic precordium, distinct
heart sounds, no murmurs
>Symmetric chest expansion,
clear breath sounds
>Full and equal pulses, no
cyanosis

Acute ST-elevated
myocardial infarction
s/p stenting of Left
anterior descending
artery

>7 episodes of watery stools,

non-bloody, non- mucoid.
>Abdominal discomfort
> feels weak after episodes of
diarrhea
>Flabby, hyperactive bowel
sounds, soft, non-tender

Lactulose induced
diarrhea

P
>Aspirin 80 mg/tab 4
tabs now, 1 tab OD after
>Atorvastatin 80mg/tab
1 OD
>Isordil 5mg SL now
>Pantoprazole 40mg IV
OD
>Enoxaparin 0.6ml SC
now then 2x a day
>Ticagradur 90mg/tab 2
tabs now then 1 tab 2x a
day
>Captopril 1 tab OD
>Tramadol and
paracetamol 1 tab TID
>Start Ranitidine
150mg/tab, 1-tab BID
>Clopidogrel 75mg/tab 1
tab OD
>Carvedilol 6.25mg 1
tab BID
>Hold Lactulose for now
>Observe for further
episodes of loose stools
>Stool charting
>IVF TF: PNSS
1LX60ml/hr
>Aspirin 80 mg/tab 1
tab OD
>Atorvastatin 80mg/tab
1 OD
>Pantoprazole 40mg IV
OD
>Enoxaparin 0.6ml SC
BID
>Ticagradur 90mg/tab 2
tabs now then 1 tab 2x a
day
>Shift Captopril to
Remipril 2.5mg/tab 1 tab
OD
>Tramadol and
paracetamol 1 tab TID
>Start Ranitidine
150mg/tab, 1 tab BID
>Clopidogrel 75mg/tab 1
tab OD
>Carvedilol 6.25mg 1tab BID
>Hold Lactulose
>Continue stool charting
>Continue IVF ratio at
60ml/hr
>Discontinue if IVF with
no loose bowel
movement

Ateneo School of Medicine and Public Health

Year Level 8: Clerkship
abdomen.
>Good skin turgor, non-sunken
eyeballs
> I&O: 2,200 & 1,580
1/24/16
1.) Chest
heaviness

2.) Diarrhea

1/25/16
1.) Chest
heaviness

>Non-fatty, non-oily diet

>Awake, comfortable and

afebrile
>No Chest pain
>No dyspnea, no syncope
episodes
>Conscious, coherent, oriented
to three spheres
>BP 100-110/60-80, HR 80-92,
RR 20-21, T 36
>Adynamic precordium, distinct
heart sounds, no murmurs
>Symmetric chest expansion,
clear breath sounds
>Full and equal pulses, no
cyanosis

Acute ST-elevated
myocardial infarction
s/p stenting of Left
anterior descending
artery

>11 episodes of watery stools,

non-bloody, non- mucoid.
>Abdominal discomfort and
heart burn
>2 episodes of vomiting
> feels weak
>Flabby, hyperactive bowel
sounds, soft, non-tender
abdomen.
>Good skin turgor, non-sunken
eyeballs
> I&O: 2,200 & 1,580
>Fecaliysis: C.defficile negative

t/c Acute gastroenteritis

>Awake, comfortable and

afebrile
>No Chest pain
>No dyspnea, no syncope
episodes
>Conscious, coherent, oriented
to three spheres
>BP 120/80, HR 70-80, RR 2021, T 36

Acute ST-elevated
myocardial infarction
s/p stenting of Left
anterior descending
artery

>Aspirin 80 mg/tab 1
tab OD
>Atorvastatin 80mg/tab
1 OD
>Pantoprazole 40mg IV
OD
>Enoxaparin 0.6ml SC
BID
>Ticagradur 90mg/tab 2
tabs now then 1 tab 2x a
day
>Hold Remipril
2.5mg/tab 1 tab OD
>Tramadol and
paracetamol 1 tab TID
>Start Ranitidine
150mg/tab, 1-tab BID
>Clopidogrel 75mg/tab 1
tab OD
>Carvedilol 6.25mg 1tab BID
>Hold Lactulose
>Start Meropenem
500mg/tab 1-tab BID
>Give metoclopramides
10mg/I now then every 8
hours as needed for
nausea/vomiting
>Give Kremil-S tablet, 1tab now
>Continue stool charting
>Continue IVF ratio at
60ml/hr
>Discontinue if IVF with
no loose bowel
movement
>Non-fatty, non-oily diet
>For fecalysis to rule out
C. dif
>Start Hidrasec tab 1
tab TID till stools are
formed
>Increase oral fluid
intake
>Aspirin 80 mg/tab 1
tab OD
>Atorvastatin 80mg/tab
1 OD
>Pantoprazole 40mg IV
OD
>Enoxaparin 0.6ml SC
BID
>Ticagradur 90mg/tab 2

Ateneo School of Medicine and Public Health

Year Level 8: Clerkship
>Adynamic precordium, distinct
heart sounds, no murmurs
>Symmetric chest expansion,
clear breath sounds
>Full and equal pulses, no
cyanosis

2.) Acute
gastroenteritis

>Stools are soft but formed, 1

episode
>No episodes of vomiting
> Feels weak
>Flabby, normoactive bowel
sounds, soft, non-tender
abdomen.
>Good skin turgor, non-sunken
eyeballs

Acute gastroenteritis
resolving

tabs now then 1 tab 2x a

day
>Tramadol and
paracetamol 1 tab TID
>Start Ranitidine
150mg/tab, 1-tab BID
>Clopidogrel 75mg/tab 1
tab OD
>Carvedilol 6.25mg 1tab BID
<May go home
tomorrow
>Hidrasec tab 1 tab TID
till stools are formed
>Increase oral fluid
intake

1/26/16
MGH

Clerk: M.M
Rotation: IM
Area:
Reference: http://www.mims.com/

Checked
by:
Signature over name of faculty