Ca - Cacao

CLINICAL ABSTRACT
L4-MDO-010 Rev 01
Name of Patient: _CACAO, APOLONIA ESCANO___ Age / Gender: 70/F

Address: B2 L11 DAISY STREET JB VILLAGE BRGY, TAGAPO, STA ROSA, LAGUNA
Attending Physician:_Dr. Amelita Brillantes_________ Room No.:T516 Hospital No.:_331398
Date Admitted: _08/29/23_ Time Admitted: 10:17AM
Date Discharged: _09/05/23__ Time Discharged: 7:02PM
Admitting Diagnosis: HYPERTENSIVE CARDIOVASCULAR DISEASE, MASSIVE PERICARDIAL EFFUSION HEART
FAILURE WITH REDUCED EJECTION FRACTION DUE TO ISCHEMIC MYOPATHY
Final Diagnosis: __MASSIVE PERICARDIAL EFFUSION; HEART FAILURE WITH REDUCED EJECTION FRACTION_
Procedure Done: ___S/P PERICARDIAL WINDOW, S/P TUBE PERICARDIOSTOMY WITH PERICARDIAL BIOPSY UNDER
SEDATION, S/P IJ CATHETER INSERTION, BLOOD TRANSFUSION 1 UNIT PRBC
Chief Complaint: Shortness of breath
History of Present Illness:

1 year prior to consultation patient sought consult to another institution and 2D echo was done which showed
concentric left ventricular hyper trophy with segmental wall motion abnormality. Minimal pericardial effusion 3 days
ago patient sought consult to another institution and 2D echo which showed massive pericardial effusion hence
consult.
PHYSICAL EXAMINATION:
General Survey: awake, conversant, not in cardiorespiratory distress
Vital Signs: BP:160/80 HR 70bpm RR: 17 cpm T: 36°CO2: 92% at room air
Skin: warm to touch, good skin turgor, no active skin lesion
Head and Neck: anicteric sclerae, pale palpebral conjunctivae, no naso aural discharge, moist oral mucosa, no
tonsillopharyngeal congestion, no cervical lymphadenopathy (+) Distended Neck Veins
Chest and Lungs: symmetrical chest expansion, no retractions, clear breath sounds
CVS: adynamic precordium, (+) muffled hearts sounds, normal rate and regular rhythm, no murmur
Abdominal: soft, flaby, normoactive bowel sounds, (+) Incision Scar, nontender
Extremities: pale palms and soles, grossly normal extremities, no cyanosis, no edema, full and equal
pulses, CRT ≤ 2sec
Neurologic Exam:
Cerebrum: Oriented to three spheres
Cerebellum: No nystagmus
CN I – can smell
CN II – pupils 2mm, equally reactive to light
CN III, IV, VI – intact extraocular muscle
CN V – can clench jaw
CN VII – no facial asymmetry
CN VIII – can hear bilaterally
CN IX, X – can swallow
CN XI – can shrug shoulders CN XII- tongue at midline
Pertinent Laboratory Examination:

(Please see attached results)
Course in the Ward:
UPH-DR. JOSE G. TAMAYO MEDICAL UNIVERSITY FOUNDATION, INC.

National Highway, Sto. Niño, City of Biñan, Laguna
Tel. No.: (632) 779-5310 / (6349) 544-5150
CLINICAL ABSTRACT
L4-MDO-010 Rev 01
Upon admission and first hospital day and subsequently admitted to CVTEL. patient was seen and assessed;
patient diet was NPO prior to OR and oral fluid intake was restricted to <1L per day. Heplock was inserted. Patient
was for lipid profile,CBC w/ Platelet Count, C-reactive Protein, Erythrocyte sedimentation rate, 12 Lead ECG, Chest X-
ray, 2D echo, Pericardial Fluid Analysis, Creatinine, ALT, Albumin, Troponin-I , and Blood typing. Nitroglycerine drip
was started. Furosemide 40mg IV. Cefazolin 500mg Iv Q12 X 6 Doses, Rosuvastatin 20mg Tab ODHS, Trimetazidine
35mg Tab Bid, Entresto 50mg Tab BID, Clopidogrel 75mg Tab OD, Paracetamol 600mg Iv Q8 X 48 Hrs, Fortifer Fa 1
Cap OD. Pericardial Window was done, Tube Pericardiostomy with Pericardial Biopsy Under Sedation was done. IJ
catheter was also Inserted patient tolerated the procedure ND 1-unit PRBC was transfused.
2nd and 3rd hospital day patient was awake, conversant, not in distress but still with shortness of breath. Diet
and IVF maintained. ISMN 60mg/Tab OD
Ezetimibe 10mg OD, Spironolactone 25mg OD, Colchicine 0.5mg BID was started. Incentive Spirometry was started.
4th hospital day awake, conversant, not in distress but still with shortness of breath. Diet was maintained, IVF
was shifted to PNSS 1L x 40cc /hr. patient was for repeat CBC with platelet count, Creatinine, Na, K, iCa, Mg,
Albumin, Norepinephrine drip, MgSO4 drip and KCL drip was started. Spironolactone and ISMN was discontinued.
Ceftriaxone 2g IV OD, Kalium Durule 1 tab QID x 10 Doses, Ivabradine 5mg Tab BID was started.
5th hospital awake, conversant, not in distress. Diet and IFC maintained. Patient was for Sputum GS/CS.
Present management continued and Patient was transferred to regular ward.
6th hospital day awake, conversant, not in distress. Diet Progressed to Low Salt Low Fat diet, Nutribest 4 scoop
in 1 glass of water OD, IVF was Maintained. Ceftriaxone was shifted to Cefixime 400 Mg 1 Tab OD. Trimetazidine 35
mg 1 Tab BID. Empagliflozin 10mg 1 tab OD was also started. Present Management was continued.
7th hospital day. Patient had stable vitals and was discharged with the following home medications:
1. Empagliflozin 10mg/tab OD
2. Ezetimibe 10mg tab OD
3. Rosuvastatin 20mg/tab OD
4. Ivabradine 5mg/tab BID hold for HR of < 60bpm
5. Clopidogrel 75mg tab OD
6. Colchicine 500mcg tab BID
7. Fortifer+ FA tab OD
8. Cefixime 400mg tab OD to complete 7 days.
Disposition: IMPROVED AND DISCHARGED
Resident/Fellow:______________________________ Clerk/ Intern-In-Charge:__PGI SALGADO,ISRAEL
Date Accomplished: ______09/01/23_______ Time: ____4:00PM___________
UPH-DR. JOSE G. TAMAYO MEDICAL UNIVERSITY FOUNDATION, INC.

National Highway, Sto. Niño, City of Biñan, Laguna
Tel. No.: (632) 779-5310 / (6349) 544-5150

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CLINICAL ABSTRACT

Name of Patient: _CACAO, APOLONIA ESCANO___ Age / Gender: 70/F

Chief Complaint: Shortness of breath

History of Present Illness:

Pertinent Laboratory Examination:

Course in the Ward:

UPH-DR. JOSE G. TAMAYO MEDICAL UNIVERSITY FOUNDATION, INC.

Disposition: IMPROVED AND DISCHARGED

Resident/Fellow:____________________________ Clerk/ Intern-In-Charge:PGI SALGADO,ISRAEL

Date Accomplished: __09/01/23_ Time: 4:00PM_________

UPH-DR. JOSE G. TAMAYO MEDICAL UNIVERSITY FOUNDATION, INC.

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