Final Typhoid Manuscript

University of Perpetual Help System - Laguna
Dr. Jose G. Tamayo Medical University

Sto. Nio, Bian, Laguna
COLLEGE OF NURSING
A.Y. : 2014 2015 1
st
SEMESTER

MYOMA:
A Case Presentation

ARAMBULO, Carol Anne T.
CABRAL, Rosemarie L.
CRUZ, Louanne Tracy B.
DALISAY, Banissa M.
DELOS SANTOS, Sean John M.
FLORALDE, Aisha F.
GABO, Ma. Angelica A.
GASPI, Feddie Anthony F.
GONZALES, Dionne Clare O.

Level IV, Section N4X, Group 4

Case Presentation: MYOMA Page 1

Table of Contents

I. Introduction....2-3
II. Patients Profile.4
III. Nursing Health History....5-6
1. History of the Present Illness.5
2. Past Health History.5
3. Family History of Illnesses..5
a. Maternal.5
b. Paternal..5
4. Position in the Family.5

IV. Nursing Assessment..6-11
a. Gordons 11 Functional Health Pattern6-9
b. Physical Assessment (Cephalo-Caudal Assessment)..10-11

V. Anatomy and Physiology12-13

VI. Pathophysiology14

VII. Medical Management...15-30

a. Doctors Order15-16
b. Laboratory/ Diagnostic Examination Results.17-25
c. Drug Study26-30

VII. Auxillary Reports31-39

VIII. Nursing Management..40-48

Nursing Care Plan40-48


I. Introduction

Uterine leiomyomata, or fibroids, are benign tumors of the uterine smooth muscle
and extracellular matrix and are extremely common in women of reproductive age. It is
thought that women are genetically predisposed to develop this condition, which is
almost always benign. Myomatous or fibroid tumors of the uterus are estimated to
occur in 20% to 40% of women during their reproductive years. Well-circumscribed
benign tumors arising from the smooth muscle of the myometrium composed of smooth
muscle, extracellular matrix, collagen, proteoglycan, fibronectin. Fibroids arise from the
muscle tissue of the uterus and can be solitary or multiple, in the lining (intracavitary),
muscle wall (intramural), and outside surface (serosal) of the uterus. They usually
develop slowly in women between 25 and 40 years of age and may become quite large.
A growth spurt with enlargement of the fibroid tumor may occur in the decade before
menopause, possibly related to anovulatory cycles and high levels of unopposed
estrogen. Fibroids are a common reason for hysterectomy because they often result in
menorrhagia, which can be difficult to control. Fibroids may cause no symptoms, or
they may produce abnormal vaginal bleeding. Other symptoms result from pressure on
the surrounding organs and include pain, backache, pressure, bloating, constipation,
and urinary problems. Menorrhagia (excessive bleeding) and metrorrhagia (irregular
bleeding) may occur because fibroids may distort the uterine lining. Fibroids may
interfere with fertility.
Using sensitive imaging techniques, cumulative incidence is as high as 70
percent among white women and more than 80 percent among African -American
women by age 50. Most fibroids are asymptomatic; however, in those women with
symptoms such as pain or heavy menstrual bleeding, there are limited treatment
options. Hysterectomy is curative (in fact, fibroids are the leading indication for
hysterectomy in the United States), but there is significant interest in identifying effective
alternatives to hysterectomy. Given the high burden of disease (including substantial
medical and nonmedical costs), significant differences in treatment choices and
outcomes among population subgroups, local variation in rates of certain treatments
such as hysterectomy, and a range of medical and invasive treatments, management of
uterine fibroids is an obvious area for comparative effectiveness research.
Symptoms usually improve in 2 to 4 weeks with treatment. The outcome is likely
to be good with early treatment, but becomes poor if complications develop. Symptoms
may return if the treatment has not completely cured the infection. Some
persons become carriers of S. typhi and continue to release the bacteria in their stools
for years, spreading the disease. Typhoid fever remains a significant health burden,
especially in low- and middle-income countries. Despite the availability of more recent
data on both enteric fevers, additional research is needed in many regions, particularly
Africa, Latin America and other developing countries. Typhoid fever remain important
public health problems globally and major causes of morbidity in the developing world.
Without effective treatment, typhoid fever has a case-fatality rate of 1030%. This
number is reduced to 14% in those receiving appropriate therapy. According to the
World Health organization, A revised estimate of the global burden of typhoid is critically
needed for developing improved strategies for disease prevention and control. The

global epidemiology of these diseases has changed with global population growth and
provision of clean water and sanitation systems. Advances in surveillance, improved
understanding of the age distribution of the disease, and more recent studies allow for
updated estimates of the global burden of typhoid fever. The most recent outbreak of
Typhoid Fever in the US was reported on 2010 in California Nevada. Where in 7 patient
were hospitalized due to contaminated tropical fruit product positive for bacteria that
causes typhoid. In the Philippines recent outbreak declared in Tuburan Cebu City after
recording 924 cases of typhoid and three deaths. The Department of Health presumed
that the residents contaminated water was the source of the disease. The annual
incidence of typhoid is estimated to be about 6 million in philippines, and is highest in
those between the ages of 5 and 12 years., the incidence of typhoid fever varies widely
between sentinel sites (annual incidence: 24/100 000 person Approximately 420 000
deaths occur annually due to typhoid fever. Without treatment, case-fatality rates of
infection are 10%. With appropriate antibiotic therapy, case-fatality rates can be
reduced to below 1%.Between 1 January and 13 November 2013, 28 224 cases of
suspected or clinically diagnosed typhoid fever were recorded in the Philippines. Two of
these cases resulted in death, yielding a case-fatality rate of 0.27%. During the same
time period in Regions 6, 7, and 8 and the National Capital Region, there were 5 637
suspected or clinically diagnosed cases and 60 laboratory-confirmed cases (Table 1).
Although the infection is treatable with antibiotics, treatment is complicated by growing
resistance to widely available oral antibiotics in several areas of the Philippines. People
can transmit the disease as long as the bacteria remain in their system; most people are
infectious prior to and during the first week of convalescence. About 10% of untreated
patients will discharge bacteria for up to three months; 2 to 5% of untreated patients will
become permanent carriers.


II. Patients Profile

NAME : N.J.L.

ADDRESS : Carmona, Cavite

GENDER : Male
AGE : 25 years 4months and 11days

BIRTHDAY : April , 09, 1989
BIRTHPLACE : San Pedro, Laguna

CIVIL STATUS : Single

NATIONALITY : Filipino

RELIGION : Roman Catholic

ADMISSION DATE : August 20, 2014

ADMISSION TIME : 10:01 am

DAYS OF HOSPITALIZATION : 3 Days
Days Handled : August 22, 2014 (1 Day)

HOSPITAL NAME : University of Perpetual Help Dr. Jose G.
Tamayo Medical Center

CHIEF COMPLAINT : Body weakness

FINAL DIAGNOSIS : Acute Thrombocytopenic Purpura, Non-
Exudative Typhoid Fever


III. Nursing Health History

1. History of Present Illness
7 days prior to admission, patient had on and off fever undocumented, non-
productive cough and throat pain and generalized body weakness. No consult was
done. Paracetamol afforded relief of fever.
1 day prior to admission, still with above symptoms, consulted at company clinic
and was given cefuroxime 500mg and paracetamol for upper respiratory tract infection.
Persistence of symptoms as well as nausea and vomitting and diarrhea
prompted consult at the emergency room of the University of Perpetual Help Dr. Jose
G. Tamayo Medical Center, hence admitted.

2. Past Health History

The patient has no history of hospitalization. He seldom contracts any illness,
and usually self-medicate with paracetamol if there is onset of fever. He usually
observes his condition before he seek consult.

3. Family History of Illnesses

a. Maternal Side: (-) Diabetes Mellitus (-) Asthma
(-) Kidney Disease (-) Respiratory Disease
(+) Hypertension (+) Heart Disease

b. Paternal Side: (+) Diabetes Mellitus (-) Asthma
(-) Kidney Disease (-) Respiratory Disease
(-) Hypertension (-) Heart Disease

4. Position in the Family

The patient is the eldest child in a brood of 5 from a 44-year old mother and a 46-
year old father. There is no reported case of illness among the siblings.

5. Vaccination

The patient is fully immunized according to age.


IV. Nursing Assessment

A. GORDONS 11 FUNCTIONAL HEALTH PATTERN
Health Perception and Management
Past Medical History

The patient has no history of grave illness, and was never hospitalized prior to
the admission in our hospital. The persistence of the symptoms was the reason why he
sought consult, the medication prescribed before hospitalization afforded only
temporary relief. Whenever he feels a bit under the weather, he would usually observe
his condition first, before seeking any medical consultation.

During Hospitalization

The patient is very cooperative when it comes to providing necessary information
regarding his illness. At the start, he felt chills and generalized body weakness. At the
hospital, he discussed how he went about this disease, and how his condition has
improved at the course of his hospital stay.

Nutritional / Metabolic Pattern

Prior to Admission

The patient doesnt cook, and is used to buying pre-prepared cooked foods at the
eatery near his boarding house and office. His usual diet consists of barbecued pork,
rice, and tapsilog. In a day, he consumes 500 ml of soda, and 4-5 glasses of
purified/mineral water. The patient is fond of drinking coffee and consumes 3-4 glasses
in a day depending on the time of his shift. He seldom eats vegetables, as well as junk
foods. He normal eats bread during his time at work, because there is a bakery next
door from where he is working. He also takes vitamin C everyday as supplement to his
diet. He is a non-smoker, and drinks alcoholic beverages approximately 4-5 glasses of
beer or 2-3 shots of hard liquor occasionally.


Patient is currently on DAT diet except dark colored foods according to age.
Intake of liquid and solid foods became lesser due to appetite loss because of his
condition, also because of fear of passing stool. He does not have the chance to take
his vitamin C as well.


Elimination

Prior to Admission

The patient regularly voids 4-5 times daily. He has bowel movement once
everyday. He does not sweat a lot, because his time is usually spent at the office where
there is air conditioning.


The patient was still able to void although his bowel movement was altered at the
course of hospitalization. He passes watery stool and nausea and vomiting was
reported at the start of his admission.

Activity Exercise

Prior to Admission

The patient has minimal activity and lives a sedentary lifestyle due to the nature
of his work. His idea of activity is to sit in front of the computer to play video games, go
surfing on the internet and log on to facebook. He only has the chance to watch
television whenever he comes home during the weekends because he doesnt own a
television set at the boarding house where he stays at during weekdays. According to
the patient, he never had the chance to exercise, as this does not interest him.


On admission, the patient carried with him his usual paraphernalia of gadgets,
his tablet, and his cellphone. He would chat with his girlfriend most of the time, and he
would surf the internet and log on facebook at the course of his stay at the hospital. He
would sleep every now and then as well as watch television.

Cognitive / Perceptual

Prior to Admission

At home, the patient is able to perform normal functioning. He considers himself
a regular guy, and is not hard to please. He is very dedicated to his career, and is keen
on succeeding in life. He would proactively join tasks where he works at because he
believes that this is important in paving way for a better future.


At the hospital, the patient is active, and would participate in the treatments being
performed by the medical professionals. He would also give feedback on how he feels

regarding the therapy, and would react on situation a person his age would given the
circumstance.

Sleep / Rest Pattern

Prior to Admission

The patient usually goes to bed at 12mn everyday. He wakes up at 8am, and
arrives at his office at 9:00am. He doesnt take naps, but he usually sleeps for 10-12
hours during the weekends or whenever he doesnt go to work.


At the hospital, he would complain that he doesnt get enough sleep because the
nurses would check up on him every now and then. His mother reported a shortened
sleeping and resting period.

Self-Perception/ Self-Concept

According to Erik Ericksons Psychosocial Theory, the patient belongs to the
young adulthood group, where there is intimacy versus isolation. In this age group,
young adults need to form intimate, loving relationships with other people. Success
leads to strong relationships, while failure results in loneliness and isolation.

Since the patient is able to go to work, he feels that he has established
relationships at work as well as form intimate relationships outside his career as
evidenced by the patient having a girlfriend.

Role Relationship

Since the patient is the eldest child, he has a sense of fulfillment when it comes
to providing assistance to his family. He said that he wants to set a good example to his
other siblings when it comes to carrying responsibility and fulfilling the role assigned to
them in their family.

Sexuality Reproductive

The patient does not have any evidence of being sexually productive yet, since
he is still single and do not have children yet.


Coping / Stress Tolerance

Prior to Admission

According to his mother, the patient is very patient, but once he gets frustrated,
he would sulk and not talk to anyone. The patient also said that he makes sure he
avoids any stress, but when he does, he takes it on playing violent video games or any
role playing games online. His favorite is to play the game called DOTA, which relaxes
him most of the time.


During his hospital admission, he would verbalize his worry about not being able
to work, and earn money. He said that he looks forward to get well as soon as possible
so that he will be able to go back to work.

Value Belief

The patients familys religion is Roman Catholic, and they would adhere to the
religions norms and activities accordingly. He seldom goes to church to hear mass.


B. PHYSICAL ASSESSMENT
(Tool: Cephalo-Caudal Assessment)

Day of Assessment: August 22, 2014
Observer: Student Nurse
Informant: Patient and Mother
Vital Signs during assessment:

Temperature: 38.9
o
C
Heart Rate: 97 bpm
Respiratory Rate: 21 cpm

Head
Area/Procedure Normal Findings Actual Findings Analysis
Skin Pinkish Pale, warm to
touch
Febrile, decreased
intravascular,
interstitial, and/or
intracellular fluid. This
refers to dehydration
with changes in
sodium. Through the
action of the pre-optic
region of the anterior
hypothalamus in
response to a bacterial
or viral infection.
Eyes Pinkish
Conjunctiva
Pale Conjunctiva,
sunken eyeballs
Buccal Mucosa Pinkish, Pale and Dry
Trunk
Skin Turgor Instant return Slow return (>3
seconds)
Result of dehydration and
poor oxygenation of the
blood.
Skin Color,
Temperature
Pinkish, warm to
touch
Pale. Skin is
warm to touch
Febrile, decreased
intravascular, interstitial,
and/or intracellular fluid.
This refers to dehydration
with changes in sodium.
Through the action of the
pre-optic region of the
anterior hypothalamus in
response to a bacterial or
viral infection.
Upper Extremities
Skin Pinkish, warm to
touch
Pale. Skin is
warm to touch
Febrile, decreased

Fingers Pinkish nailbeds
without
curvature, and
capillary refill of
(<2seconds)
Pale nailbeds
with decreased
capillary refill (>3
seconds)
This is caused by
decreased local circulation
and increased extraction
of oxygen in the peripheral
tissues.

Lower Extremities
Skin Pinkish, warm to
touch
Pale, warm to
touch
Febrile, decreased
Through the action of the
pre-optic region of the
anterior hypothalamus in
response to a bacterial or
viral infection.


V. Anatomy and Physiology
The Digestive System
The functions of the digestive system are:
Ingestion - eating food
Digestion - breakdown of the food
Absorption - extraction of nutrients from the food
Defecation - removal of waste products
The digestive system also builds and replaces
cells and tissues that are constantly dying.
Digestive Organs
The digestive system is a group of organs (Buccal
cavity (mouth), pharynx, oesophagus, stomach, liver, gall
bladder, jejunum, ileum and colon) that breakdown the chemical components of food,
with digestive juices, into tiny nutrients which can be absorbed
to generate energy for the body.
The Buccal Cavity
Food enters the mouth and is chewed by the teeth,
turned over and mixed with saliva by the tongue. The
sensations of smell and taste from the food sets up reflexes
which stimulate the salivary glands.
The Salivary glands
These glands increase their output of secretions through three
pairs of ducts into the oral cavity, and begin the process of
digestion.
Saliva lubricates the food enabling it to be swallowed and
contains the enzyme ptyalin which serves to begin to break down starch.


The Pharynx
From the pharynx onwards the alimentary canal is a simple tube starting with the
salivary glands.
The Oesophagus
The oesophagus travels through the neck and thorax, behind the trachea and in
front of the aorta. The food is moved by rhythmical muscular contractions known as
peristalsis (wave-like motions) caused by contractions in longitudinal and circular bands
of muscle. Antiperistalsis, where the contractions travel upwards, is the reflex action of
vomiting and is usually aided by the contraction of the abdominal muscles and
diaphragm.
The Stomach
The stomach lies below the diaphragm and to the left of the liver. It is the widest
part of the alimentary canal and acts as a reservoir for the food where it may remain for
between 2 and 6 hours. Here the food is churned over and mixed with various
hormones, enzymes including pepsinogen which begins the digestion of protein,
hydrochloric acid, and other chemicals; all of which are also secreted further down the
digestive tract.
The stomach has an average capacity of 1 litre, varies in shape, and is capable
of considerable distension. When expanding this sends stimuli to the hypothalamus
which is the part of the brain and nervous system controlling hunger and the desire to
eat.
The wall of the stomach is impermeable to most substances, although does
absorb some water, electrolytes, certain drugs, and alcohol. At regular intervals a
circular muscle at the lower end of the stomach, the pylorus opens allowing small
amounts of food, now known as chyme to enter the small intestine.

Situated at the back of the nose and oral cavity receives the softened food mass
or bolus by the tongue pushing it against the palate which initiates the swallowing
action.
At the same time a small flap called the epiglottis moves over the trachea to
prevent any food particles getting into the windpipe.

MODIFIABLE:
environment
unsanitary food handling
ingestion of
contaminated food and
water
living in overcrowded
area
socio economic status
immunization

SIGNS AND SYMPTOMS:
(untreated/relapse)
Carphologia
Sordes
Generalized aches
Abdominal Pain
Intestinal
bleeding/perforation after
2-3 weeks
Pneumonia, peritonitis

NON-MODIFIABLE:
age
gender
nationality

Ingestion of contaminated food
and water with salmonella typhi

Invades epithelial cells in the
intestine and enter the
bloodstream temporarily by WBC

Macrophages in the intestine
engulf salmonella typhi

Bacteria spread through
lymphatics and acces
reticuloendothelial system, liver,
bile duct, spleen, gallbladder, and
bone marrow and pass into the
bowel
TYPHOID FEVER
SIGNS AND SYMPTOMS:
Nausea and vomiting
High grade on and off
fever (38.9
o
C)
Diarrhea (watery stool)
Lethargy

VI. Pathophysiology

Prognosis: Death (if no
improvement/relapses)
Good Prognosis


VII. Medical Management
A. Doctors Order

Date

Doctors Order

Analysis
8/20/14
11:50pm
Please admit to ICU under the
service of Dr.R
For further management
Secure consent for admission and
management

For any clarification
NPO

IVF left arm Plain Lactated Ringer
1Lx 8hours
Right arm Plain Lactated Ringer
1Lx 8hours

Labs PTT,CT,BT,12lead ECG,
HGT,Urinalysis,Trans Vaginal
Ultrasound once stable

For Blood Transfussion of 2units
Fresh whole blood and 4units pack
RBC, properly type and cross
matched to run for 4hours without
interval

For co-management with internal
medicine or deck

Give calcium gluconate 1 amp IV
after fourth unit of blood

Insert indwelling Foley catheter now
Monitor vital signs every 15 minutes For baseline data
Watch out for blood transfusion
reaction

Refer
Attending physician informed For further management
Adendum
For Na, K, BUN, Crea, Calcium,
MG, SGPT, ABG

Other labs care of internal medicine
Give ceftriaxone 1gm IV after
negative skin test every 12 hours
Refer to drug study
Report complete blood count after
6 units of blood


Paracetamol 1amp IV now Refer to drug study
PRN for T 38 celcius
Okay for referral to internal medicine
for co-management

9/13/14 Internal medicine
11pm - Tthank you
very much for this referral patient
seen and examined. History and
labs reviewed, patient is a 49
years old female who came in
due to body weakness. Patient is
non-hypertensive, non-diabetic
diagnose with intra abdominal
mass un recalled year. No
surgical intervention done, mass
was noted to change size of
monthly menses.

HPI 3 days prior to admission
positive menses consuming for soak
napkin/day no easy fatigability, no
palpitation,no chest pain,no consult
done, no meds taken, 1 day prior to
admission negative menses now with
generalized body weakness, no
consult done, persistence of the body
weakness prompted consult at
community hospital, hence admitted

PE awake, coherent not in cardio
respiratory distress, afebrile, pale
looking, anicteric schlera, pale
palpebral conjunction, BP 100/70 PR-
123 clear breathe sounds no
wheezes or crackles no retraction,
tachycardia, regular rhythm abdomen
soft positive 20 by 20 firm, + movable
non-tender, no edema regular pulse

Impression anemia
secondary to chronic blood loss
secondary to abdominal uterine
bleeding, intra abdominal mass,
etiology unknown, acute kidney
injury secondary to pre-renal
azotemia UTI contracted

Plan
start FeSO4 tab 1 tab TID

vitamin k 1 amp/IV now
vit b. tab BID
folic acid 5g/capsule OD
paracetamol 300mg IV q4 PRN
for T37.8 celcius

agree with present antibiotic
please follow up urine GC/CS
watch out for transfusion
reaction, hypertension, fever,
restless pruritus, severe back
pain

May have diet as tolerated
Doctor O. informed of this
regard via SMS

Decrease oxygen to 1 2L/min
via nasal cannula

Decrease IVF to KVO while on
blood transfusion

9/14/14
6:30AM
Internal Medicine notes
Attending Physician updated
Give furosemide 40mg IV now Refer to drug study
Follow up urine gram stained
Facilitate transvaginal
ultrasound

Suggest to discontinue PLR get
blood transfusion and HR spare
then repeat after 3 minutes
sitting

Discontinue Tranexemic Acid
Diet As Tolerated
Continue IVF
8:20AM Continue meds
Ceftriaxon 1gm IV every 12hrs
day one
FeSO4 tab 1 tab BID
Vitamin B tablet 1 tab BID
Follic acid 5mg/ capsule 1cap
OD
Paracetamol 300mg IV every
4hours T > 37.8C to 37.5C

Refer to drug study
Still for blood transfusion for 4
units packed RBC properly type
and crossmatched

Give calcium gluconate 1 amp

IV after 4
th
unit of blood
For report CBC with platelet
6hrs post blood transfusion of
6
th
unit of blood

Still for transvaginal ultrasound
care of OB sonologist

Follow up unit GS/SC
Routine O2 via nasal cannula
at 1 2L/min

For blood transfusion
reactions

Monitor vital signs and urine
output every hour
For baseline data
Refer
8:45AM Give paracetamol 500mg/tab 1
tab for every 4hours for + >
37.8C

Carry out suggestion of
medicine

Refer
11AM Please follow upd transvaginal
ultrasound

May relay GS once in
Continue meds
Facilitate blood transfusion as
directed

PNSS 1L x 120cc/hr, KVO
during blood transfusion

4:50PM Continue present management
Diet As Tolerated
IVF to follow PNSS 1L x 8hrs
decreased for KVO once in
blood transfusion
To maintain hydration
status
Continue meds
Increased oral fluids For hydration
Have perineal hygiene To promote good hygiene
Still for blood transfusion 3
more units packed RBC
properly type and
crossmatching

Give calcium gluconate 1 amp
slow IV push after 4
th
unit of
blood
To avoid gastric acidity and
prevention of abdominal
pain
For report CBC and platelet
6hrs post blood transfusion 6
units of blood


For transvaginal ultrasound CD
OB sinologist once patient is
stable

Follow up result of urine GS/SC
Retained indwelling foley
catheter

Watch out for blood transfusion
reaction, pruritus, congestion,
fever

Advice tepid sponge bath for
fever

Monitor vital signs and urine
output and every 1 hour

Refer
8PM May give furosemide 400mg IV
now,hold for systolic BP < 90
Refer to drug study
Attending Physician updated For further
Relay CBC with platelet once in
Continue present
meds/management

Refer
9/15/2014 Give furosemide 400 mg IV
now

Facilitate follow up 4 units
packed RBC and transvaginal
ultrasound

Repeat CBC with platelet as
ordered

Refer
7AM Diet As Tolerated
Continue IVF PNSS 1L x KVO
while on blood transfusion, then
to run x 8hrs

Continue meds
Ceftriaxon 1gm thru IV every
12hrs dose 2 day 1
FeSO4 tab 1 tab TID
OD
Paracetamol 500mg/tab 1 tab
every 4hrs for fever T > 37.8C
4hours T > 38.5C

Still for blood transfusion one

more unit packed RBC properly
type and crossmatched
For repeat CBC platelet 6hrs
post blood transfusion 6
th
unit
of blood

For transvaginal ultrasound
care of OB sonologist

Follow up urine GS/CS day
two

Retained indwelling foley
catheter

Continue oxygen via nasal
cannula at 1 2L/min

Monitor V/S and urine output
every hour

Refer
9:15AM For transvaginal ultrasound
care of OB sinologist (Dr.A)

Please instruct relatives to have
patient listed at MAB 302 at
around 1 to 3 pm for
transvaginal ultrasound under
Dr. A

Refer
11:30AM Internal medicine
If 4
th
unit preload RBC will not
be available by today plan to do
CBC with platelet count if okay
with main service

Plan to do ALT, AST, total
bilirubin direct and indirect
albumin and alkaline
phosphatase if okay with main
service (OB gyne)

Rounds with Dr. O
Suggest transfer of referral to
hematologist

No objection if for transout
11:45AM Carry out labs as suggested by
medicine

May transfer service to
hematologist as referral

May transfer to room if stable
and asymptomatic

Refer

12:10PM Okay to refer DR. B as
hematologist

Okay to transout patient to ICU
12:30PM Dr. B out of town, Dr C as her
reliever

12:45PM Okay be to be referred to Dr. C
as reliever of Dr. B

1:20pm IVF to follow PNSS1L x 80cc/hr
Dr, C informed of this referral
via SMS

1:30pm Dr.C will not be able to make
rounds for Dr.B no new
referrals from now she will be
back on the 18
th
of september

Informed Dr.O informed and
updated

3:50am Rounds with Dr.R For further management
Okay for repeat CBC with
platelet now

For repeat trans vaginal
ultrasound care OB sinologist
care of Dr.A

May repeat CBC with platelet
after blodd transfusion of 6
th

units of blood (final) properly
type and crossmatched please
facilitate

Refer
4:24pm for repeat CBC with platelet
now

9/16/14 Internal medicine
12am Vaginal 49yrs old female non-
hypertensive, non-diabetic
history noted, heavy vaginal
bleeding by 2 years came in
due to pallor, dizziness, general
body weakness

TRR every shift and record
please

Diet as tolerated
IVF PNSS 1L x 20cc/hr For rehydration and
correction of electrolyte
imbalance
Labs pending; AST,ALT,direct
bilirubin, indirect bilirubin,
alkaline phosphatase, CBC with


platelet count
Meds
12hrs dose 2 day 1
FeSO4 tab 1 tab TID
OD
Paracetamol PRN

O2 inhalation 2-3L/min via nasa
cannula PRN

Moderate high back rest
Secure 2 units packed RBC
properly type and
crossmatched

Vital sign q4 and record
Refer
9:20am diet as tolerated
continue IVF PNSS 1Lx KVO For rehydration and
imbalance
Continue meds
12hrs dose 2 day 1
FeSO4 tab 1 tab TID
OD
Paracetamol 500mg/tab 1 tab
every 4hrs for fever T > 37.8C
4hours T > 38.5C

Refer to drug study
Follow up urine GS/CS
Follow up pending labs;
Labs pending; AST,ALT,direct
bilirubin, indirect bilirubin,
alkaline phosphatase, CBC with
platelet count

give O2 inhalation 2-3l/min via
nasal cannula PRN

vital sign q 2 with urine output
refer
9:30am rounds with Dr.R
continue present management
suggest to medicine if
indwelling foley catheter can be


removed carry out suggested
medicine for total abdominal
ultrasound secure consent
vital sign every 4 hours
refer
11am rounds with Dr.O
refer for cardiac clearance
repeat ABG today and relay
refer
transfuse 2 units packed RBC
properly type and
crossmatched

1:10pm okay to refer to cardio on deck
2:25pm pulmo
Chest x-ray, PA (9/13) done
ABG (9/16); 7.44/37.9/81/26.2

assessment moderate risk for
pulmonary complication
Recommendation
1. intraoperative pulse oximeter
monitoring
2. hydrocortisone 150mg IV 2
doses prior to surgery
3. proceed with plan referral to
hematology

4pm diet as tolerated
continue IVF PNSS 1L x KVO For rehydration and
imbalance
continue meds
for exlap TAHBSO 1CP cleared
follow up cardiac clearance
still for blood transfusion of 2
and cross matched

removed indwelling foley
catheter now

monitor vital sign if on blood
transfusion otherwise q 4

refer
4:30pm rounds with Dr.T
suggest for correction of
anemia thru transfusion of 3
and cross matched

for 2D-echo now To monitor various problem

with the heart
continue med
refer
9/17/14 facilitate 2D-echp To monitor various problem
with the heart
6:04am attending physician updated For further management
6;50am diet as tolerated
continue IVF PNSS 1L KVO
continue meds
start ascorbic acid 500mg tab 1
tab OD

follow up urine CS day 4
facilitate 2D-echo as requested
by internal medicine
To monitor various problem
with the heart
for blood transfusion of 3 more
and cross matched

for CP clearance care of
internal medicine

plan for exlap, TAHBSO once
cleared

give O2 inhalation 2-3L/min via
nasal cannula PRN

daily oral hygiene
pad count please
monitor vital sign q 2 while on
blood transfusion

refer

B. Laboratory / Diagnostic Examination Results

Name: N. J. L. Age: 25 Sex: Male Date Submitted: 08/20/14

Referring Doctor: E.C.J. Room/Bed No.: ER

LABORATORY REPORT

URINALYSIS

Color: Yellow Glucose: Negative
Transparency: Slightly Hazy Specific Gravity: 1.020
Reaction (pH): 6.5 Pus Cells: 1-2/HPF
Protein: Trace RBC: 0-1/HPF
Mucus Threads: Few


LABORATORY REPORT

Name: N. J. L. Age: 25 Sex: M Date: 08/19/2014
Dept./Ward/Rm/Bed #: Hosp. #: Lab #:
Req. Physician:

HEMATOLOGY

TEST NORMAL VALUES ACTUAL RESULT SIGNIFICANCE
WBC Count 4.5 - 11.0 4.4 x10^9/L
RBC Count 4.6 - 6.2
Hemoglobin
120 - 150

156.2 g/L
High hemoglobin is usually
due to an increased
number or abnormality of
red blood cells
Hematocrit
0.40 - 0.54

0.47

Segmenters 0.45 0.65 0.74
High levels usually
represent and ongoing
infection, an
inflammation,
malignancy, caused by
some drugs.
Platelet Count 150 - 450 300 x10g/L
DIFFERENTIAL COUNT:
Neutrophils 0.50 0.70 0.73
There may be damage or
inflammation of tissues or
high levels of stress
placed on the body.

Lymphocytes 0.20 - 0.50 0.26
Monocytes 0.02 0.08
Basophils 0.00 0.02

Diagnosis:
Others: Normocytic, Normochromic


Lab No.: 08212014-03 Hospital No.: Date: 08/21/2014
Name: N. J. Age: 25 Sex: Male
Physician: Dr. E. R. Ward: T302 Specimen: Serum

CLINICAL CHEMISTRY

Test Name
SI Unit Conversional Unit
Flag Normal
Range
Result Normal
Range
Result
SGPT (ALT)
SGOT (AST)
BUN
CREATININE
SODIUM
POTASSIUM

LOW
0.0 41.0
0.0 37
2.5 7.2
53 115.0
137 145
3.5 - 5.1
22.50 U/L
25.00 U/L
2.38 mmol/L
96.50 umol/L
140.10 mmol/L
3.72 mmol/L
0.0 41.0
0.0 37
7.0 20. 16
0.60 1.3
137 145
3.5 - 5.1
22.50 U/L
25.00 U/L
6.67 mg/dL
1.09 mg/dL
140.10 mEq/l
3.72 mEq/l

REMARKS:
DENGUE DUO
IgM Antibody: NEGATIVE
IgM Antibody: NEGATIVE

*BUN Decreased value may indicate hemodilution, liver failure, low protein intake,
malabsorption, nephrotic syndrome, starvation. Urea is the final product of protein
metabolism within the body. Deoending upon the amount of protein ingestion and
adrenal gland activity, the production of urea in the body is varied. Other factor that
contribute to the level of urea in the body are medical conditions such as fever and
diabetes. With respect to the production of urea, the BUN test provides an index to
evaluate the glomerular function.


LABORATORY REPORT
Name: N.J.L. Age: 25 Date Requested: 8/20/2014
Physician: E.C.J. Sex: Male Date Submitted: 8/20/2014

HEMATOLOGY
TEST RESULT NORMAL VALUES SIGNIFICANCE
Hemoglobin 154 gm/L 120 - 150
High hemoglobin is
usually due to an
increased number or
abnormality of red blood
cells
Hematocrit 0.46 0.40 0.54
RBC Count 5.21 x10^12/L 4 5.6
WBC Count 4.19 x10^9/L 5.0 10.0
A low count can indicate
the presence of one or
more serious health
problems, such as
leukemia,
hyperthyroidism, aplastic
anemia, or an infectious
disease.
Lymphocytes 0.27 0.20 0.40
Monocytes 0.10 0 0.05
Monocytes elevated may
suggest inflammation
present
Eosinophils

0 0.04
Basophiles 0.01 0 0.01

MCV 88.6 fl 80 - 98
MCH 29.5 pg 26 - 32

MCHC
333 g/L 320 - 360

Platelet Count
144 x10/L 150 400
Low platelet count may
decrease if the bone
marrow does not
produce enough
platelets.

RDW
11.9 % 11 - 15


LABORATORY REPORT
Name: N.J.L. Age: 25 Date Requested: 8/21/2014
Physician: E.C.J. Sex: Male Date Submitted: 8/21/2014

HEMATOLOGY
TEST RESULT NORMAL VALUES SIGNIFICANCE
Hemoglobin 139 gm/L 120 - 150
Hematocrit 0.42 0.40 0.54
RBC Count 4.70 x10^12/L 4 5.6
WBC Count 2.87 x10^9/L 5.0 10.0
A low count can indicate
the presence of one or
more serious health
problems, such as
leukemia,
hyperthyroidism, aplastic
anemia, or an infectious
disease.
A low count indicates a
reduction in either the
number or the size of red
blood cells.
Lymphocytes 0.39 0.20 0.40
Monocytes 0.11 0 0.05
Monocytes elevated may
suggest inflammation
present
Eosinophils

0.01 0 0.04
Basophiles 0 0.01 .
MCV 88.7 fl 80 - 98

MCH 29.6 pg 26 - 32

MCHC
333 g/L 320 - 360

Platelet Count
123 x10/L 150 400
Low platelet count may
decrease if the bone
marrow does not produce
enough platelets.

RDW
12.0 % 11 - 15


IMMUNOLOGY SECTION

NAME: N. J. L. AGE/SEX: 25/MALE
ROOM: T302/T3 DATE: 08/21/2014
SPECIMEN: SERUM EXAMINATION; TYPHIDOT

TYPHIDOT TEST: IgM: NEGATIVE
IgG: POSITIVE

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