Medical Abstract

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REMEDIOS TRINIDAD ROMUALDEZ HOSPITAL
CALANIPAWAN ROAD, TACLOBAN CITY

June 23, 2012

MEDICAL ABSTRACT

A case of Martinez, Socorro P., 70 years old, female, married, Filipino, Roman Catholic, a resident of Brgy. 96 Calanipawan, Tacloban City, was admitted at RTRH for the second time on June 15, 2012 around 6:20 am with a chief complaint of difficulty of breathing.

Patient’s condition started 5 days prior to admission, when she had sudden onset of fever. She took Alaxan 500 mg tab once. There were no other associated manifestations noted such as cough, colds, chest pain, and dyspnea. No consultation was done.

Three days prior to admission, fever persisted and was now associated with body malaise. She took Paracetamol 500 mg tab once which offered temporary relief. Night prior to admission, symptoms persisted and was now associated with difficulty of breathing. Persistence of symptoms prompted patient to seek consult, hence the admission. She is a known hypertensive for 7 years with unrecalled maintenance medication. She has family history of Cardiovascular Disease on paternal side. She is a Brgy. Kagawad, a non-smoker and non-alcoholic beverage drinker. She has no known allergies to food and drugs.

Upon admission, she was examined conscious, coherent, with the following vital sings of BP 160/90 mmHg, HR 81 bpm, RR 25 cpm and temperature of 37.5 C. Significant physical findings include (+) tight airways, (+) rales, (+) occasional wheeze. O2 inhalation via nasal cannula at 3-4 L/min was given. Venoclysis of PLR 1 L at 20 gtts/min was started. She was on full low salt, low fat diet. Diagnostics were requested such as CXR PA which revealed Bronchitis, CBC which showed elevated WBC of 15.45 with predominance of Neutrophils 0.77. Urinalysis was light yellow, slightly turbid, RBC of 4-6/hpf and Pus Cells of 5-10/hpf. Medications were prescribed such as Salbutamol + Ipratropium nebulization Q 6 H, Hydrocortisone 200 mg IVTT Q 6 H, Procaterol 25 mcg...
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