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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Arriola, Corazon Age/Sex: 63/F Address: 1354 Burgos St. Paco Manila Date of admission: August 25, 2007 Admitting Diagnosis: Complicated UTI DM Type II HCVD CAD NSR II-B Residents in charge: Drs.Aguila/Receno/Dimaandal CIC: Palay/Rentillo/Roxas

Hospital #: 1727009

24 hour history This is a case of a 63 year-old female who came in to IM-ER due to vomiting. History of Present Illness 2 days PTA, patient had vomiting of previously ingested food nonbloody. This was associated with dysuria, undocumented fever which was temporary relieved by intake of paracetamol, headache which is frontal in location and loss of appetite. No chills notes. No consult done. 1 day PTA, there was persistence of vomiting still associated with dysuria, loss of appetite, and generalized body weakness which prompted consult at IMER. She was diagnosed with UTI HCVD, CAD, NSR II-B. Patient was given ceftriaxone IV initially and was eventually sent home with the following meds: Ciprofloxacin, Metoprolol, Glibenclamide and ASA. Few hours PTA, patient at home, no vomiting noted but she was unable to eat. There was still generalized body weakness with chills. No abdominal pain noted. Difficulty of moving was observed. Persistence of symptoms prompted consult hence the admission. Past Medical History (+) DM x 2 years meds: Glibenclamide. (+) HPN no maintenance medication (-) heart disease (-) other previous hospitalization nor operation. Family History Patient denies heredofamilial disease. Personal and Social History Nonsmoker and nonalcoholic beverage drinker Review of Systems General: no weight loss HEENT: blurring of vision, no tinnitus Respiratory: no cough, no hemoptysis, no difficulty of breathing Cardio: no palpitation, no PND, no orthopnea GIT: no change of bowel movement GUT: (-) hematuria Hematologic: no easy brusability Neurologic: no seizure Physical Examination: Patient was awake, not in cardiorespiratory distress Vital Signs: BP: 160/90 HR: 86 RR:20 Temp: 36.7oC HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, CHEST AND LUNGS: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, NRRR, no murmur ABDOMEN: flabby, NABS, soft, non-tender EXTREMITIES: grossly normal, FEP, no edema, no cyanosis Assessment: Complicated UTI DM Type II HCVD CAD NSR II-B Course in the Ward: Upon admission, NGT was inserted and was placed on OF feeing at 21 kcal divided into 3 equal parts +2 snacks. IVF PNSS 1L x 8 hours was hooked. Diagnostics requested were 12 lead ECG, CBC c PC, urinalysis, CXR- PA, FBS, BUN, Crea, BUA, Na, K, cholesterol, TG, HDL, LDL, HgBA1C. Therapeutics given was: 1. Ceftriaxone 2g TIV OD ANST 2. Paracetamol 300 mg/amp TIV for temp ≥38C. 3. Metoclopramide 1 amp TIV q8 4. Glibenclamide5mg 1 tab ODor BP >160/100 5. imidapril + HCTZ 10 mg tab OD PO 6. NIfedipine 10mg/cap 1 cap SL prn for BP≥160/100 7. Regular Insulin 5uSQ prn for CBG≥250mg/dL


				
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