Name of Patient: Atienza, Angelita

Room No.: 1416

Submitted by: Philip D. Principe
Internal Medicine
Admission Date: November 24, 2016
November 30, 2016

Age: 52
Sex: Female
Department:
Date:

OFF-SERVICE NOTES/PROGRESS NOTES

Respectfully endorsing patient AA, a 52 year old female who was admitted due to vomiting.
Patient was apparently well until 2 days prior to admission, when patient had one episode of
nonprojectile, non-bilous vomiting which was described as watery and approximately half a cup.
Patient noted that this was associated with headache, epigastric pain, flank pain, and generalized
body weakness. There was no accompanying cough, colds, fever, hematochezia, melena, or
hematemesis. No medication and consult done. One day prior to admission, there was persistence
of symptoms and it was noted that there was drying of the oral mucosa. Patient experienced 10
bouts of vomiting. It was noted that the patient experienced shortness of breath and difficulty of
breathing. There was also 2 pillow orthopnea and feeling of drowning when lying down which
prompted consult at another institution where she was treated as URTIand was given Cefuroxime.
Patient opted to be transferred in our institution and was subsequently admitted.
Past Medical History:
Patient is a known hypertensice since 2014 and she has a history of cerebrovascular disease last
2015. This year she was diagnosed of heart disease. She was previously hospitalized due to
elevated blood pressure. Her current medications are Cefuroxime 500mg, Dolcet, Furosemide
40mg OD, Aldadone 25mg OD, Losartan 50mg and Atorvastatin 80mg. There was no documented
childhood sickness, accidents, previous surgeries, encountered injuries or allergies to medication
or food. There was no documented dermatologic, hematologic, respiratory, gastro-intestinal,
reproductive, musculoskeletal, neurological, neoplastic diseases or history of recent infection
Family History:
Family history reveals hypertension at the maternal side and kidney disease at paternal side.
Other than these, there was no history of recent infection, hematologic, dermatologic, respiratory,
gastro-intestinal, reproductive, endocrine, musculoskeletal, neurological and neoplastic diseases
documented in the family.
Personal and Social History:
Patient currently lives with her children. She has no food preference and eat three times a day.
She has no allergy to any food or medication. She is a non-smoker nor an alcoholic beverage
drinker with no history of illicit drug use.
S>

No new current subjective complaints. (-) fever, (-) headache, (-)

O>
General: Patient is awake, conscious and able to follow commands, not in cardiorespiratory distress.
Vital Signs: BP 110/80 mmHg, PR 85 bpm, RR 18cpm, T 36.5 C

SHEENT: Patient has a brown-complexity, senile dry skin. (-) cyanosis, jaundice, pallor. (-)
CLADS
Respiratory: Upon inspection, patients chest has an equal symmetrical chest expansion
with fine crackles on both lung fields.
Cardiovascular: Normal rate, regular rhythm, no murmurs.
Abdomen: Upon auscultation, there is normoactive bowel sounds of around 9 per minute
with soft nontender, symmetrical, no abdominal scars, spider angiomas, discoloration, mass,
peristalsis present. No tenderness upon palpation on all quadrants.
Extremities: There is no presence of atropy, tenderness, edema, varicosities, masses,
jaundice, pallor, cyanosis noted.
Neuro: All cranial nerves grossly intact.
A>
Acute symptomatic hyponatremia;
Congestive heart Failure NYHA Class II
P>

Complicated

Urinary

Tract

Infection;

Aspirin 80mg/tab OD PC

Clopidogrel 75mg/tab ODPC

Losartan 50mg/tab ODAM

Atorvastatin 80mg/tab 1/2 tab ODHS

Paracetamol 500mg/tab q6 PRN headache

Metoclopramide 10mg IC q8 PRN

Pantoprazole 40mg/tab OD

Azithromycin 500mg/tab OD

Iterax 25mg/tab ODHS

KCL tab TID

Paracetamol 300mg IV PRN x Temp >

Tramadol 50mg IV q8 x breakthrough pain

Vitamin B Complex/tab OD

Fixcom 4 three tabs OD Pre breakfast

Duavent Nev q8 prn x DOB

Fluimucil 600mg in 1/2 glass H2O

Fluimucil 600mg 2 tabs q12

Unasyn 750mg/tab BID

38.5