OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: BUSTAMANTE, CORAZON Age/Sex: 58/F Address: Pacheco Tondo Manila Date of admission: July 21,2007 Admitting Diagnosis: LGIB prob 2 to 1. Diverticulosis 2. Colonic Malignancy HCVD, ICUBBR, NSR II-B Residents in charge: Dr. Lucero, de los Reyes, Filio, Indon Intern-in-Chage: Clerk-in-Charge: Navarro/Ponelas/ Reyes
Hospital #: 1711699
24 h history
This is a case of a 58 year-old female who was admitted due to generalized body weakness History of Present Illness Patient is a known case of LGIB in this institution in this institution since 2005 s/p EGD with normal results. Last admission was July 2,2007 due to pallor admitted for 3 days s/p blood transfusion. Advised to have colonoscopy on OPD basis. Patient was apparently with no symptoms of melena until at 1 day PTC patient had generalized body weakness, pallor, easy fatigability, dizziness upon standing up. No melena, no hematochezia, no hematemesis, no abdominal pain no vomiting. Persistence prompted consult hence the admission. Past Medical History + HPN , - DM, BA,CAD Family History +HPN - DM,CVD, CA, CKD, asthma Personal and Social History Non smoker, Non alcoholic beverage drinker Review of Systems No anorexia, with weight loss of 107 in 1 month HEENT: no head ache, no epistaxis, no tinnitus Respiratory: (-) colds, (-) hemoptysis Cardiac: (-) PND, Gastrointestinal: (-) abdominal pain, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Muscular: + general body weakness Physical Examination: conscious, coherent, in cardiorespiratory distress Vital Signs: BP: 90/60 HR: 108 RR: 23 Temp: 37 HEENT: pale palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (-) distended neckm veins CHEST AND LUNGS: symmetrical chest expansion, - retraction, (-) crakles , (-) wheezes HEART: adynamic precordium,PMI 5th ICS LMCL , no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: full equal pulses, no edema Assessment: LGIB prob 2 to 1. Diverticulosis 2. Colonic Malignancy HCVD, ICUBBR, NSR II-B PLAN: Patient was admitted under the service of Drs. Lucero/ Gozales/Filio/Indon. Consent for admission and management was secured. Patient was placed on low salt, low fat diet with SAP. IVF to ff was PNSS x 1 L x 8h to KVO once on BT. Previously ordered labs were cbc c pc, blood typing, colonoscopy barium enema, 12 L ECG, CXR-PA, BUN, creatinine, urinalysis, FBS, HDL, LDL, TG, TC, BUA. Therapeutics include: 1) Captopril 25 mg 1 tab SL prn for BP > 160/90 2.) Imidapril + HCL tab OD 3.) FeSO4 tab TID. Patient scheduled for Ba enema, for stool exam with occult blood, for BT 3 u PRBC properly typed and crossmatched.moderate to high back rest , VS q2, WOF hypotension, active bleeding. On the 1st HD, patient was referred to gastro service consultant, PWI: LGIB prob 2 to 1.)angiodysplasia 2.) colonic ca. Patient for indirect bilirubin determination, for PBS, for F/A with occult blood d/c FeSO4 tab 3 days prior to examination. Patient placed on general liquid diet c SAP. IVF to ff: PNSS 1L x 8h, for colonoscopy, repeat cbc c pc, still for transfusion of 2 u PRBC, moderate to high back rest, VSq2, I and O monitoring, CBG AC/HS.