OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: Zacarias, Gemma Age/Sex: 36/F Address: 91-J Central Kalayaan, Pasay City Date of Admission: July 21, 2007 Admitting Diagnosis: UPPER RESPIRATORY TRACT INFECTION Final Diagnosis: URTI Residents-in-charge: Drs. Montoya/Aguila/Raceno/Dimaandal Clerks-in-charge: Ocampo G/ Patayan/Roque 48H History This is a case of a 36 year old female who came in due to cough.
Hospital #: 1711842 Room #: #317
History of Present Illness Two days prior to consultation, patient had productive cough with mucoid phlegm and colds. There was also occasional difficulty of breathing. There was no chest pain, no abdominal pain, no fever, nodysuria, no diarrhea. Persistence of symptoms prompted consultation hence the admission. Past Medical History No HPN, no DM, no asthma, no heart disease, no previous hospitalizations Family History No HPN, no DM, no asthma, no heart disease Personal/Social History: Non-smoker Non alcoholic beverage drinker Review of Systems: General: no weight loss, no loss of appetite Skin: no pallor, no rashes, no jaundice HEENT: no tinnitus, no blurring of vision, no dysphagia, no epistaxis Cardiovascular: no chest pain, no PND, no palpitations, no orthopnea, no easy fatigability Abdomen: no diarrhea, no constipation, no melena, no heamtochezia GUT: no dysuria, no oliguria, no heamturia, (+) nicturia Endocrine: no polyuria, no polyphagia, no polydipsia Hematologic: no easy bruisability, no bleeding tendencies Neurologic: no seizure, no loss of consciousness, no syncope Physical Examination: Patient is conscious, coherent, not in cardiorespiratory distress o Vital Signs BP: 120/80 HR: 80 bpm RR: 18 cpm Temp: 37 C (axillary) HEENT: anicteric sclerae, pale palpebral conjuctiva, no naso-aural discharge, no palpable cervical lymph nodes, no neck mass, no tonsillopharyngeal congestion, no neck vein distention Chest and Lungs: Symmetrical chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: Flat, normoactive bowel sounds, soft, (+) direct tenderness on hypogastric area Extremities: grossly normal, no cyanosis, no edema, full equal pulses Neurologic: conscious, coherent, oriented to time, person and place. Assessment: Plan: Upper respiratory tract infection
Course in the Wards: Upon consent of the patient, admitted with the following standing orders: Input and output monitoring every shift, TPR every shift, regular diet and diagnostic laboratory procedures (CBC with PC, Urinalysis, and BUN, CREA, Na, K, Cholesterol, TG, HDL and LDL)
Medications given were (1) Co-amoxiclcav 625mg/tab thrice a day per orem and (2) Ascorbic acid 500mg tab thrice a day, also per orem. She was maintainrd on moderate high back rest and was monitored every hour. st nd On her 1 and 2 hospital, patient’s vital signs were within normal range, hence present management and medications were continued. Her vital signs were monitored every two hours. nd At 7:00 PM on her 2 hospital day, patient went out on pass.