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9/22/10
4pm
A: initial VS taken and recorded as follows T= 37.2, RR=21, PR=94, BP= 140/90.
Oriented to hospital rules and policies. Provided with additional layers of blankets.
Facilitated requests for blood extraction at 6pm such as CBC, SGPT, BUN, &
creatinine. Blood extractions for FBS, cholesterol and triglycerides to be done
tomorrow. Instructed family members to inform staff of patient’s last meal today.
*1st rounds done. Febrile @ 38.3. instructed by NPO from 8pm-8am for blood
extraction.
D: awake, lying on bed with serum osmolality, urine NA, urine osmolality, PPt, serum
Na 6 hours after hooking 3% NaCl. WOF seizures
A: vs taken and recorded, afrebrile, advise pt regarding lab test. Advise pt NPO.
9/23/10
6am-2pm
8am
D: seen conscious and coherent for blood extraction and urine specimen collection
for 2D echo and Doppler.
*facilitated ancillary procedures. Noted revised diet. IVF shifted to PNSS @ 30cc/
hour with repeat Na extraction 6 hours after hooking to PNSS 1L. endorsed for
sputum AFB in 3 consecutive days.
2-10pm
D: awake on moderate back rest; with ongoing IVF PNSS 1L @ 30cc/hour. Stable VS
for repeat Na 6 hours post hooking of PNSS. No complaints of pain no pending
diagnostics.
10-6pm
R: stable, safe
9/24/10
6am-2pm
10am
D: seen awake, sitting on bed, afebrile, not in distress. IVF #4, 0.9 NaCl infusing @
30 gtts/min. (- ) pain
D: Na=122. Not in distress or pain. No DOB, adequate urine output. Availing results
of latent blood extraction
A: Vs taken and recorded- due meds given. IVF regulated at desired rate. IVF
infusing well.
HISTORY
3weeks PTA the patient was noted to have generalized body weakness. They consulted and
was requested blood tests which showed increased creatinine, increased BUN and uric acid.
Patient’s weakness was accompanied pain on the knee, ankle, and the toe on the right foot.
Patient didn’t complain not until the pain was already graded 10/10. Then was scheduled to
have a consultation here in Manila. But due to his progressive weakness they have been
postponed. Few days PTA the pt felt better hence consult.
PAST HX:
(+) HPN
(-)DM
(-)ASTHMA
FAMILY HX:
(+) HPN
(+)DM
(-)ASTHMA