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CASE ABSTRACT

This is the case abstract of the patient named E.C. 43 years of age, female admitted last August 01, 2012 around 1pm with the chief complaints of abdominal distention. She had an admitting vital signs of temperature = 36C Respiratory Rate = 32breaths per minute Pulse Rate = 95 beats per minutes and Blood Pressure = 110/80 mmHg. Her admitting physician was Dr. Matela and her admitting diagnosis was to consider ascitis prob. 2 to malignancy. Dr. Matella ordered a close monitoring to the vital sign of the patient every 1 hour because the patient is also experiencing difficulty of breathing. Patient has Oxygen 5L/m via nasal cannula and she was also given salbutamol for bronchodilator. Her admitting physician also requesting NPO diet to the patient until her respiratory rate is going back to normal range. And the patient was administering an IVF which is PLR x 8 hours. Her physician was also requesting some laboratory exam for the patient which is the CBC, Chest X-ray, Arterial Blood Gas, Ultra sound, Urinalysis with the administration of the following drugs; Phytomenadione,Furosemide (Lasix),azithromycin,Rosuvastatin ,cefoxitin, cefuroxime .

BIOGRAPHICAL DATA
Name: C. E Age: 43 years old Gender: female Civil status: Single

Address: Pilar Jimenez ST. Bautista Compound Talon 1, Las Pinas City Birth date: July 11, 1969 Religion: Roman Catholic Occupation: None Birth Place: Las Pinas City Educational Attainment: Undergraduate Place of Employment: None

Language Spoken: English/Tagalog Health financing: shouldered by her sister Admitting diagnosis/Impression: T/C Ascitis Prob. 2 to Malignancy Admitting Physician: Dr. Matella Source of Information: Chart/Patient/Patients Sister Reliability (1-4 with 4 very reliable): 4

NURSING HISTORY
Chief Complaints: Abdominal Distention History of present illness: 5 months prior to admission patient had already ascitis then she was admitted to San Juan De Dios for Abdominal Paracentesis. Then after the procedure done to the patient she taught that thats her last hospitalization for this year but 1 month prior to admission she felts that her abdomen is getting bigger. And she thinks she looks like pregnant women then she go to, to her doctor for consultation then her doctor found out that she had an ascitis and need to have an abdominal paracentesis.

PAST MEDICAL HISTORY


Childhood illnesses: According to the patient her childhood illnesses is only measles when she is in elementary. Immunization status: Patient said she completed all the immunization. Allergies: Patient has No Known Allergies Accidents and Injuries: According to the patient she doesnt experience any accidents and Injuries in her entire life. Hospitalization (Cause/Organ Damage/Removed/Treatment): Last April 2012, patient was admitted in San Juan De Dios for the same reason which is ascitis. She is also undergone abdominal Paracentesis. Medication taken:

FAMILY HISTORY
Health State and Ages of (cause of death if deceased) Parents: Patient father is deceased due to emphysema and her mother is hypertensive Siblings: Patient siblings dont have any diseases. Spouse: Patient is Single Children: Patient only child is deceased. Illness in the family similar to the patient: According to patients sister her tita has the same illness to the patient.

Case Analysis of Ovarian Cancer


Submitted By: Mark Angelo Jacosalem (Pathophysiology) Jacqueline Lim (Anatomy and Physiology) Ma. Rosario Levita (Laboratory and Diagnostic Exams) Raymond Lansang (NCP) Mark Vincent Inofinada (P.E) Frederick Gonzalez (P.E) Lucille Ibaoc (Case Abstract) Louie Gonzaga (Learning Objectives) Deniz Shen Hernandez (Drug Study)

Submitted To: Mrs. Renee Malvaz, RN, MAN