Nobleza_24 by dredwardmark

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Nobleza, Martin Age/Sex: 69/M Address: 1354 – A 4 Burgos St. Paco Manila Date of admission: August 26, 2007 Admitting Diagnosis: Urosepsis BPH PTB IV Residents in charge: Drs.Dalanon/Gutierrez/Gregorio CIC: Palay/Rentillo/Roxas

Hospital #: 1723904

24 hour history This is a case of a 64 year-old female who came in to IM-ER due to fever History of Present Illness Patient was previously treated with UTI. Initially given cotrimoxazole 800/160mg BID x 7 days without relief of symptoms He consulted a private MD and was prescribed with Norfloxacin 400mg BID, Sambong caps and Prednisone. Few hrs PTA, there was persistence of symptoms which prompted consult and subsequently, this admission. Past Medical History (+) PTB – Completed treatment for 6 months (+) BPH no medications (-) HPN, DM, BA Family History (-) HPN, DM, BA Personal and Social History 30 pk/yr smoker and nonalcoholic beverage drinker Review of Systems General: no weight loss, no anorexia HEENT: no blurring of vision, no tinnitus, no headache Respiratory: no cough, no hemoptysis, no difficulty of breathing Cardio: no palpitations, (-) orthopnea (-) PND GUT: (-) hematuria, no oliguria Hematologic: no easy brusability Neurologic: no seizure, no LOC Physical Examination: Patient is conscious coherent, not in cardiorespiratory distress Vital Signs: BP: 120/90 HR: 81 RR:20 Temp: 36.9oC 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, PMI at 5th ICS LMCL, NRRR, no murmur ABDOMEN: flabby, NABS, soft, nontender EXTREMITIES: grossly normal no cyanosis with full equal pulse. (-) edema DRE: good sphincteric tone Assessment: Urosepsis BPH PTB IV Course in the Ward: Upon admission, Patient was placed on regular diet with SAP. He was hooked to IVF: PNSS 1L x 6 hours. Diagnostic procedures requested were urine culture, 12-lead ECG, CBC c PC, urinalysis, CXR- PA, Blood CS x 2 sites, FBS, BUN, Crea, Na, K, HDL, LDL, TG, cholesterol, BUA, KUB UTZ with prostate, sputum AFB x3. Therapeutics given were: 1. Piperacillin – Tazobactam 2.25 g IV q8 ANST 2. Paracetamol 500mg IV q4 PRN for T≥385°C


								
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