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Housewife
From Legazpi City
Chest Pain
1 week
On and off retro sternal sharp chest pain Easy fatigability Chest tightness Diaphoreses Difficulty of breathing Vomiting
Few hours
admission
difficulty of swallowing
with poor compliance Non-DM No previous Hospitalization No history of any surgical operation No allergy to food and drugs
(-) DM
(-) Cancer (-) bronchial asthma
Non - smoker
General Survey:
Conscious Coherent Diaphoretic In cardio-respiratory distress
Vital Signs
BP: 70/50 mmHg CR: 52 bpm RR: 25 cpm Temp: 36oC Weight: 51kg Height: 54 BMI: 23 O2 sat : 97-98%
HEENT: Pink palpebral conjunctiva anicteric sclerae no naso-aural discharge, no tonsillo-pharyngeal congestion
Neck:
No cervical lymphadenopathies
no mass (+) neck vein engorgement
Chest/Lungs:
Symmetrical chest expansion (+) retractions subcostal
Bibasal crackles
Heart: Adynamic precordium, Apex beat at 5th left ICS, AAL, Bradycardic, regular rhythm, no murmur
Abdomen: flabby Normoactive bowel sounds 8 cm liver span midclavicular line and 5 cm midsternal (+) epigastric tenderness no guarding and rigidity
Extrenities:
Difficulty of breathing
Chest pain Diaphoresis
Epigastric pain
Engorged neck vein Bibasal crackles
Bipedal edema
GERD
Pulmonary Embolism
RULE-OUT Tearing pain Murmur Bruits Unequal pulses Trop-I:negatiive Diminished breath sounds over hemithorax Trop-I: Negative
Pneumothorax
GERD
Pulmonary embolism
IVF w/ D5W
Dopamine drip
WBC
Hemoglobin
Hematocrit Platelet count Neutrophils 41
8.1
114
0.38 145 59 26
Medication:
Fondaparinux 2.5 mg sq, OD
ASA 80 mg 4 tabs Stat chewed then 1 tab OD Clopidogrel 75mg 4 tabs Stat chewed then 1 tab OD Atorvastatin 80mg 1 tab @ HS
Lactulose 30cc @ HS
FC II
P> 2D Echo once stable Repeat 12-L ECG Start Trimetazidine 35mg/tab, BID Fondaparinux 2,5 mg SQ OD Furosemide 20 mg IV q8 provided SBP >100mmhg Spironolactone 25 mg tab, OD Lanzoprazole 30 mg tab, OD continue Dopamine drip
Chole: 5.3 mmol/L Trigly: 1.63 mmol/L N HDL: 0.9 mmol/L LDL: 3.67 mmol/L VLDL: 0.7 mmol/L Chol/dHD: 6.18 Urea: 5.4 mmol/L Crea: 101 umol/L K: 4.1 mmol/L Calcium: 2.54 mmol/L ALT: <3 U/L
3rd
Hospital day
grade 1 O> BP: 95/50- 115/64 mmhg CR:80 bpm RR:22 cpm A> Acute Coronary Syndrome, NSTEMI, in SR, CHF, FC II P> Continue Dopa drip
Labs:
Color Transparency Reaction Specific gravity Yellow Sl. turbid 6 1.020
Pus cells
RBC Epithelial cells Bacteria Albumin Sugar
1-2/hpf
0-1/hpf Few Few negative negative
Magnesium Na K
5th Hospital day: S> BP: 140/80 mmhg CR: 65 bpm RR: 23 cpm O> (-) chest pain, , (-) DOB, bipedal edema A> Atherosclerotic heart disease, Acute Coronary Syndrome, NSTEMI, in SR, CHF, FC II P> Continue medication May transfer to cardio ward shift furosemide IV to 20mg/tab 12-L ECG
IHD
ACS
No ST Elevation
ST Elevation
NSTEMI (Trop-I: +)
STEMI
demand.
Or by increase in myocardial oxygen demand
nonocclusive thrombus.
2. Dynamic Obstruction 3. Progressive mechanical obstruction 4. 2ndry UA related to increased myocardial oxygen
Clinical History/P.E.
Chest pain
Dyspnea
Epigastric dyscomfort
Diaphoresis
Pale cool skin Sinus tachycardia
Basilar rales
Hypotension
Description of Stage
Ordinary physical activity does not cause angina Slight limitation of ordinary activity.
Anti-ischemic agents
Anticoagulants
Antiplatelets Coronary revascularization
Anti coagulant:
Fondaparinux 2.5 SQ, Enoxaparin 1 mg/kg subcutaneously q12
Antiplatelets:
ASA, initial dose of 160-325 mg followed by 75-100mg
Fundaparinux:
Catalyzes factor Xa inhibition by antithrombin and does not enhance the rate of thrombin inhibition.
Is cleared unchanged via kidneys , it is contraindicated in
which is important in aggregation of platelets and cross-linking by the protein fibrin. The blockade of this receptor inhibits platelet aggregation by blocking activation of the glycoprotein IIb/IIIa pathway.
Atorvastatin: inhibit HMG reductase. Lactulose: The metabolites of lactulose draw water into the
improves myocardial glucose utilization through inhibition of fatty acid metabolism, also known as fatty acid oxidation metabolism.
Furisemide: loop diuretic. By inhibiting the transporter, the
irrespective of cholesterol levels, in the aim of achieving LDLc < 2.6 mmol/L.
Use of beta-blocker
BB are appropraite anti-ischemic therapy and may help
irrespective of cholesterol levels, in the aim of achieving LDLc < 2.6 mmol/L.
Use of beta-blocker
BB are appropraite anti-ischemic therapy and may help
Thank You