Client Presentation
Transcript: Client Presentation History of Present Illness -7 days prior to admission, patient had undocumented fever accompanied by headache and body malaise AFTER wading in water at a farm in Quezon PROGRESS NOTES (+) Undocumented fever (1 week) (+) headache (+) body malaise (+) difficulty in urination (+) calf pain (+) vomiting (>10) of previously ingested food EMERGENCY ROOM April 13, 2013 - 2:30PM Chief Complaint of Difficulty on Urinating The physician noted calf muscle tenderness, vomiting and scanty urine output, thus the physician has ordered -Insertion of Foley Catheter and placed on Oxygen Support at 2-3 lpm via nasal cannula. - Vital Signs every 4 hours - Intake and Output Monitoring every shift - DAT EDCF PNSS IL fast drip of 200cc then regulate for 6hrs Prior to admission at Pavilion III Adolescent Ward, Insertion of Foley Catheter was done with latest urine output of 20cc and Chest X-ray has been performed. Facilitate Arterial Blood Gas NOW, SGPT, SGOT Serum Na, K, Cl, RBS and HBsAG Refer again to Resident on Duty after 30mins regarding patient's urine output. 30 minutes after... Fast drip 400cc of PNSS Refer 30mins after Fast drip 400cc of PNSS 11:45pm Fast drip 400cc of PNSS Refer 30mins after Reassessment was done with no new orders -Start KCl tablet 1 tab three times a day -increase oral fluid intake -Repeat Creatinine Masakit po yung tiyan ko Yung parang pinipilipit yung sakit, sa may epigastric area po atsaka 7/10 po. April 14, 2013 1:45pm T: 36.0 C PR: 68bpm RR: 26cpm BP:100/70mmHg Increase the Intravenous Fluid rate of PNSS IL x 166 ml/hr to 220 ml/hr for 4 hours then regulate to 140 cc/hr -Start Ranitidine 50mg TIV every 8 hours for abdominal pain April 16, 2013 6:30am Repeat BUN, Creatinine and CBC with APC (-) calf pain afebrile (-) N/V Adequate Urine output (+) Adherence to antibiotic treatment - Result of MAAT done at PGH confirms infection of Leptospirosis You may go home anytime today. Take Doxycycline 100mg; 1 tab, 2x a day for 3 days then follow-up check up at the nearest health care facility in your community. Total Intake Intravenously and Orally was 5000cc with a total urine output for 24 hours is 2100cc with No Bowel Movement. Dr. Igrobay Family Medicine Date of Extraction: Dr. Manese Family Medicine patient’ vital signs are as follows: T= 36.8C PR=60bpm, RR= 18cpm and BP of 100/60mmHg -urine output of 30cc April 13, 2013 - 6:15pm 7:45pm 14 Urine output of 30cc SAN LAZARO HOSPITAL Test Name Result Reference Ranges Potassium 2.78 mmo/L 3.50-7-20mmol/L Chloride 100.4 mmol/L 98-108 mmo/L Sodium 130.40mmol/L 135-145 mmol/L EMERGENCY DEPARTMENT April 14, 2013 Patient E.N.A.'s Total Intake of Fluids is 5560cc with a Total urine output of 3350cc with No Bowel Movement. 7:00 AM Patient's total input is 1300cc Total Output of 200cc April 13,2013 7:15pm -Paracetamol 500mg/tab every 4 hours for fever. -Pen G 2 million “U” through IV every 6 hours after negative skin test. Date of Extraction: Dr., patient is afebrile but still experiences epigastric pain 1:45pm Dr. Igrobay Family Medicine I have no Past Medical History, no Allergies on any medication and no Family History of Cancer, Diabetes Mellitus and Hypertension ADOLESCENT WARD I will kink your Foley Cather and please inform me if there's an urge. We will remove your Foley Catheter after 3 urges. It's more fun in the Philippines! I will refer you to San Lazaro Hospital which specializes on Infectious Diseases April 17, 2013 Patient is on Day 4 of hospitalization, with negative fever, myalgia, nausea and vomiting, jaundice and with good muscle activity and adequate urine output. April 13, 2013 - 5:30pm -Shift Ranitidine 50mg TIV every 8 hours to Omeprazole 40mg TIV once a day -Hold KCl tablet -Repeat Serum K -CBC with APC -Urinalysis -BUN, Creatinine -LAAT -MAAT Chest X-Ray That's good news! I'll be ordering to -Remove Indwelling catheter after bladder training -Discontinue KCl tablet -Continue present management Dr. Manese Family Medicine Apparent prominence of the pulmonary vascular markings may be due to supine position, No focal infiltrates or consolidation seen, Heart is magnified, Diaphragm and Sulci are intact, visualized bony thorax is unremarkable. 12 I took Paracetamol 500mg/tab which gave me temporary relief pH of 7.41 (NV: 7.35-7.45) PCO2 of 37 mmHg (NV: 35-45mmHg) PO2 of 136.8 (80-100mmHg) HCO3 of 22.9meqs/L (NV: 22-26meqs/L) Please facilitate the ff. laboratory test for our baseline data - Urinalysis -Creatinine Hi I'm E. N. A., i am 15 years old, Born on Aug. 8, 1997, I live in Brgy. Alitas, Infanta Quezon, i'm a Filipino and a Roman Catholic, I weigh 44kg Dr., the patient's urine output is still 20cc since admission, I have already started Pen G 2M "u" ANST Apr APR Clinical Chemistry Test Name Result Reference Ranges BUN 23.95 mmol/L (H) 2.50-7.20mmol/L Creatinine 447.20 umol/L (H) 71-115 umol/L 12 The next day... 6:40pm APR Apr Your Laboratory Results show good prognosis! You can now go home! 6AM Patient's urine output is