basa

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE Name: Basa, Buenvenida Hospital #: 1803698 Age/Sex: 79/F Address: 360 Bacood Sta.Mesa , Manila Date of Admission: February 23, 2008 Admitting Diagnosis: Sepsis probably 2º decubitus ulcer, gluteal area right, grade 2 HCVD, NSR, NIR Residents-in-charge: Drs. Roxas/Cuz Clerks-in-charge: Barrion/Bartolazo/Cabarles 24 HOUR HISTORY This is a case of a 79 year old female from Sta. Mesa, Manila who came in due to generalized body weakness. HISTORY OF PRESENT ILLNESS 2 weeks prior to admission, patient had a decreased appetite with generalized body weakness. There were no fever, no vomiting, no chest pain and no dyspnea 1 week prior to admission,persistence of above symptoms.There was no consult done. Persistence f generalized body weakness prompted consult. PAST MEDICAL HISTORY (+) hpn X 3 years- maintained on Imidapril with good compliance s/p CVD 2002 with left residual No Diabetes Mellitus, no Asthma, No allergies. NO history of Hypertension. FAMILY HISTORY Denied heredofamilial diseases. PERSONAL/SOCIAL HISTORY Non smoker, non alcoholic beverage drinker REVIEW OF SYSTEMS: Constitutional: No fever. (+) weight loss. HEENT: No blurring of vision. No dizinness. No tinnitus. No dysphagia. Integument: No rashes. No pruritus. Hair: No hair loss. Respiratory: No dyspnea. No cough, no colds, no hemoptysis. Cardiovascular system: No orthopnea. No PND. No easy fatigability. Genitourinary system: No dysuria. No gross hematuria. No incontinence and urinary retention. No genital pruritus. Neuromuscular: No pain. No stiffness. No seizures, tremors, convulsions. Hematopoeitic sytem: No easy bruising. No gum bleeding, epistaxis. No observed prolonged bleeding. No hematemesis. Endocrine system: No heat and cold intolerance. No sluggishness, hoarseness. No polyuria, polydipsia and polyphagia. PHYSICAL EXAMINATION General: drowsy Vital Signs: BP: 110/80 HR: 92 RR: 24 Temp: 36 C SHEENT: Anicteric sclerae, pale palpebral conjunctivae, No Nasoaural discharge, No Cervicolymphadenopathy, no neck vein engorgement Chest and Lungs: Symmetrical chest expansion. No lagging. No retractions. No crackles. No wheezes. Heart: Adynamic precordium, Normal rate, regular rhythm, no murmurs. PMI at the 5 th left midclavicular line. Abdomen: flabby, Normoactive bowel sounds, soft, non tender on palpation. Extremities: Grossly normal, No edema, no cyanosis. Full and equal pulses Assessment: Sepsis probably 2º decubitus ulcer, gluteal area right, grade 2 HCVD, NSR, NIR Plan: For admission COURSE IN THE WARDS: Patient was admitted under the service of Drs. Roxas/Cruz. Patient was placed on NPO and NGT was inserted. IVF was PNSS 1L x 8 hours . O2 support was via nasal face mask at 10 lpm.Laboratory work ups requested were ECG, CXR PA, CBC c PC, Blood typing, Urinalysis, BUN, creatinine,Na, K, TG,HDL, LDL, TC, FBS and blood culture. Medications were Piperacilline – Tazobactam 2.25mg TIV q8 ANST, Omeprazole 40mg TIV OD,Paraetamol 300mg TIV, 1 ½ amp TIV PRN for fever and Captopril 25mg/tab , 1 tab/NGT for BP>160/100. At 12:30pm, oral feeding at 1800 kcal divided in 3 equal feeding was started. IVF was shifted to D5W 500cc x 6 hours. KCL tab, 3 tabs TID/NGT was also given. Patient was referred to surgery for wound debridement.Patient was placed on moderate to high back rest.Vital signs monitored every 1 hour and CBG monitoring q8. On the 1st hospital day, NGT and OF were maintained. IVF was D5W500 cc x 6hours . O2 support was via nasal face mask at 10 lpm.Medications were continued. Patient was placed on moderate to high back rest and was advised to turn back side to side.Vital signs monitored every 1 hour and CBG monitoring q8. OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE Name: Basa, Buenvenida Hospital #: 1803698 Age/Sex: 79/F Address: 360 Bacood Sta.Mesa , Manila Date of Admission: February 23, 2008 Admitting Diagnosis: Sepsis probably 2º decubitus ulcer, gluteal area right, grade 2 HCVD, NSR, NIR Residents-in-charge: Drs. Roxas/Cuz Clerks-in-charge: Barrion/Bartolazo/Cabarles 48 HOUR HISTORY This is a case of a 79 year old female from Sta. Mesa, Manila who came in due to generalized body weakness. HISTORY OF PRESENT ILLNESS 2 weeks prior to admission, patient had a decreased appetite with generalized body weakness. There were no fever, no vomiting, no chest pain and no dyspnea 1 week prior to admission,persistence of above symptoms.There was no consult done. Persistence f generalized body weakness prompted consult. PAST MEDICAL HISTORY (+) hpn X 3 years- maintained on Imidapril with good compliance s/p CVD 2002 with left residual No Diabetes Mellitus, no Asthma, No allergies. NO history of Hypertension. FAMILY HISTORY Denied heredofamilial diseases. PERSONAL/SOCIAL HISTORY Non smoker, non alcoholic beverage drinker REVIEW OF SYSTEMS: Constitutional: No fever. (+) weight loss. HEENT: No blurring of vision. No dizinness. No tinnitus. No dysphagia. Integument: No rashes. No pruritus. Hair: No hair loss. Respiratory: No dyspnea. No cough, no colds, no hemoptysis. Cardiovascular system: No orthopnea. No PND. No easy fatigability. Genitourinary system: No dysuria. No gross hematuria. No incontinence and urinary retention. No genital pruritus. Neuromuscular: No pain. No stiffness. No seizures, tremors, convulsions. Hematopoeitic sytem: No easy bruising. No gum bleeding, epistaxis. No observed prolonged bleeding. No hematemesis. Endocrine system: No heat and cold intolerance. No sluggishness, hoarseness. No polyuria, polydipsia and polyphagia. PHYSICAL EXAMINATION General: drowsy Vital Signs: BP: 110/80 HR: 92 RR: 24 Temp: 36 C SHEENT: Anicteric sclerae, pale palpebral conjunctivae, No Nasoaural discharge, No Cervicolymphadenopathy, no neck vein engorgement Chest and Lungs: Symmetrical chest expansion. No lagging. No retractions. No crackles. No wheezes. Heart: Adynamic precordium, Normal rate, regular rhythm, no murmurs. PMI at the 5 th left midclavicular line. Abdomen: flabby, Normoactive bowel sounds, soft, non tender on palpation. Extremities: Grossly normal, No edema, no cyanosis. Full and equal pulses Assessment: Sepsis probably 2º decubitus ulcer, gluteal area right, grade 2 HCVD, NSR, NIR Plan: For admission COURSE IN THE WARDS: Patient was admitted under the service of Drs. Roxas/Cruz. Patient was placed on NPO and NGT was inserted. IVF was PNSS 1L x 8 hours . O2 support was via nasal face mask at 10 lpm.Laboratory work ups requested were ECG, CXR PA, CBC c PC, Blood typing, Urinalysis, BUN, creatinine,Na, K, TG,HDL, LDL, TC, FBS and blood culture. Medications were Piperacilline – Tazobactam 2.25mg TIV q8 ANST, Omeprazole 40mg TIV OD,ParaCetamol 300mg TIV, 1 ½ amp TIV PRN for fever and Captopril 25mg/tab , 1 tab/NGT for BP>160/100. At 12:30pm, oral feeding at 1800 kcal divided in 3 equal feeding was started. IVF was shifted to D5W 500cc x 6 hours. KCL tab, 3 tabs TID/NGT was also given. Patient was referred to surgery for wound debridement.Patient was placed on moderate to high back rest.Vital signs monitored every 1 hour and CBG monitoring q8. On the 1st hospital day, NGT and OF were maintained. IVF was D5W500 cc x 6hours . O2 support was via nasal face mask at 10 lpm.Medications were continued. Patient was placed on moderate to high back rest and was advised to turn back side to side.Vital signs monitored every 1 hour and CBG monitoring q8. On the 2nd hospital day, NGT and OF were maintained. IVF was D5W500 cc x 6hours. O2 support was via nasal face mask at 10 lpm. Na and K determination were done.Medications were continued. NGT and OF were maintained. IVF was D5W500 cc x 6hours . O2 support was via nasal face mask at 10 lpm.The patient was still for wound debridement.Medications were continued. Patient was placed on moderate to high back rest.Vital signs monitored every 1 hour and CBG monitoring q8. OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE Name: Basa, Buenvenida Hospital #: 1803698 Age/Sex: 79/F Address: 360 Bacood Sta.Mesa , Manila Date of Admission: February 23, 2008 Admitting Diagnosis: Sepsis probably 2º decubitus ulcer, gluteal area right, grade 2 HCVD, NSR, NIR Residents-in-charge: Drs. Roxas/Cuz Clerks-in-charge: Barrion/Bartolazo/CabarleS PATIENT’S DISCHARSE SUMMARY This is a case of a 79 year old female from Sta. Mesa, Manila who came in due to generalized body weakness. HISTORY OF PRESENT ILLNESS 2 weeks prior to admission, patient had a decreased appetite with generalized body weakness. There were no fever, no vomiting, no chest pain and no dyspnea 1 week prior to admission,persistence of above symptoms.There was no consult done. Persistence f generalized body weakness prompted consult. PAST MEDICAL HISTORY (+) hpn X 3 years- maintained on Imidapril with good compliance s/p CVD 2002 with left residual No Diabetes Mellitus, no Asthma, No allergies. NO history of Hypertension. FAMILY HISTORY Denied heredofamilial diseases. PERSONAL/SOCIAL HISTORY Non smoker, non alcoholic beverage drinker REVIEW OF SYSTEMS: Constitutional: No fever. (+) weight loss. HEENT: No blurring of vision. No dizinness. No tinnitus. No dysphagia. Integument: No rashes. No pruritus. Hair: No hair loss. Respiratory: No dyspnea. No cough, no colds, no hemoptysis. Cardiovascular system: No orthopnea. No PND. No easy fatigability. Genitourinary system: No dysuria. No gross hematuria. No incontinence and urinary retention. No genital pruritus. Neuromuscular: No pain. No stiffness. No seizures, tremors, convulsions. Hematopoeitic sytem: No easy bruising. No gum bleeding, epistaxis. No observed prolonged bleeding. No hematemesis. Endocrine system: No heat and cold intolerance. No sluggishness, hoarseness. No polyuria, polydipsia and polyphagia. PHYSICAL EXAMINATION General: drowsy Vital Signs: BP: 110/80 HR: 92 RR: 24 Temp: 36 C SHEENT: Anicteric sclerae, pale palpebral conjunctivae, No Nasoaural discharge, No Cervicolymphadenopathy, no neck vein engorgement Chest and Lungs: Symmetrical chest expansion. No lagging. No retractions. No crackles. No wheezes. Heart: Adynamic precordium, Normal rate, regular rhythm, no murmurs. PMI at the 5 th left midclavicular line. Abdomen: flabby, Normoactive bowel sounds, soft, non tender on palpation. Extremities: Grossly normal, No edema, no cyanosis. Full and equal pulses Assessment: Sepsis probably 2º decubitus ulcer, gluteal area right, grade 2 HCVD, NSR, NIR Plan: For admission COURSE IN THE WARDS: Patient was admitted under the service of Drs. Roxas/Cruz. Patient was placed on NPO and NGT was inserted. IVF was PNSS 1L x 8 hours . O2 support was via nasal face mask at 10 lpm.Laboratory work ups requested were ECG, CXR PA, CBC c PC, Blood typing, Urinalysis, BUN, creatinine,Na, K, TG,HDL, LDL, TC, FBS and blood culture. Medications were Piperacilline – Tazobactam 2.25mg TIV q8 ANST, Omeprazole 40mg TIV OD,Paraetamol 300mg TIV, 1 ½ amp TIV PRN for fever and Captopril 25mg/tab , 1 tab/NGT for BP>160/100. At 12:30pm, oral feeding at 1800 kcal divided in 3 equal feeding was started. IVF was shifted to D5W 500cc x 6 hours. KCL tab, 3 tabs TID/NGT was also given. Patient was referred to surgery for wound debridement.Patient was placed on moderate to high back rest.Vital signs monitored every 1 hour and CBG monitoring q8. On the 1st hospital day, NGT and OF were maintained. IVF was D5W500 cc x 6hours . O2 support was via nasal face mask at 10 lpm.Medications were continued. Patient was placed on moderate to high back rest and was advised to turn back side to side.Vital signs monitored every 1 hour and CBG monitoring q8. On the 2nd hospital day, NGT and OF were maintained. IVF was D5W500 cc x 6hours. O2 support was via nasal face mask at 10 lpm. Na and K determination were done.Medications were continued. NGT and OF were maintained. IVF was D5W500 cc x 6hours . O2 support was via nasal face mask at 10 lpm.The patient was still for wound debridement.Medications were continued. Patient was placed on moderate to high back rest.Vital signs monitored every 1 hour and CBG monitoring q8. On the 3rd hospital day, NGT and OF were maintained. IVF was D5W500 cc x 6hours . O2 support was via nasal face mask at 10 lpm.The patient was seen by the surgeons with their working impression of Grade II ulcer, proximal 3rd , lateral aspect of thigh, Right. Wound debridement was done.Medications were continued. Patient was placed on moderate to high back rest.Vital signs monitored every 1 hour and CBG monitoring q8. On the 4th hospital day, NGT and OF were maintained. IVF was D5W500 cc x 6hours . O2 support was via nasal face mask at 10 lpm. Medications were continued. Patient was also for daily wound debridement.Patient was placed on moderate to high back rest.Vital signs monitored every 1 hour and CBG monitoring q8. Summary of Laboratory Results: Normal Values 9 4.8-10.8 x 10 /L 12 4.0-6.20 x 10 /L 12-16g/dl 37-47 % 80-90 fL 27-31 32-36 150-400 x 10^9/L 55-57 20-30% 0-7% 0-3% 0-1% 2/22 6.5 5.31 15.1 45.9 86.3 28.4 32.9 210 4 6.4 WBC RBC Hgb Hct MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphous Urates Pus Cells Erythrocytes Bacteria Fine granular cast Hyaline cast Feb 23 Dark Yellow Turbid Many Many Moerate 3-5 1-3 Parameter BUN Creatinine Na K Cl Triglycerides HDL LDL Cholesterol Glucose Feb 23 43.62 255 160 2.2 108 Feb 25 Feb 26 159.6 2.73 1.79 3.34 5.3 Normal values 1.7 -8.3.4mmol/L 59-104Umol/L 135-148mmol/L 3.6-5.2mmol/L 98-108mmol/L 0.45-1.81mmol/L 0.78-1.82mmolL 2.22-5.13mmol/L 3.09-7.31 mmol/L 3.9-6.4 mmol/L