Patient’s Profile
Name: T.M
Age: 46
Religion: RC
Address: Quezon City
Birthdate: 05/09/63
Civil status: married
Occupation: none
Cc: LBM
Medical Dx: Acute Renal Failure
Attending Physician: Dr. A.R
Present Medical Hx
Three days prior to admission,
patient had loose bowel
movement of about five times
associated with vomiting more tan
ten times, and abdominal pain.
No consultation done, no med’s
taken two days prior. Pt still on
above symptoms developed fever
promptly consult then admitted
Past Medical Hx
• (-) HPN
• (-)PTB
• (+)DM
Family Medical Hx
• (+) HPN
• (+)DM
Personal Social Hx
Since 20 yrs old, the patient was a
alcohol drinker and a smoker
Body Part Methodology Normal Actual
of Assessment findings findings
I. Upper
Extremities
1. hands & nails INSPECTION
a. color Pinkish Cyanotic
b. temp Nor cold, nor Cold to touch
c. texture warm
Smooth Rough
d. turgor Good skin turgur Poor skin turgur
e. presence of No lesion No lesion
lesions
f. edema No presence With edema
2. Brachial PALPATION Good pulsation Weak pulse
pulse
3. forearm & INSPECTION
upper ar,
a. tenderness INSPECTION
4. ROM INSPECTION No limitation Bed rest
II. Head
1. Hair & scalp INSPECTION
a. quantity Good in quality, Good in quality
thickness and Soft & silky hair
texture
b. distribution Well distributed Well distributed
c. lesions No lesions No lesions
2. Face INSPECTION
a. facial Good facial Facial grimace
expression expression
1. lower
extremities
UROBILINOGEN
Serology
PROCEDURE RESULT
TROPONIN-I POSITIVE
KUB-(UTZ)
IMPRESSION:
before use.
>Bacteremia
>Meningitis
>Acute bacterial
otitis media
5.Metoclopromid >To prevent or > Contraindicated in >Tell patient to aviod activities
e reduce nausea >Stimulates motility patients that require alertness
andvvomiting from of upper GI tract hypersensitive to
Hydrochloride IV emetogenic increases drugs and in for 2 hours after doses.
MALAXONCLOP cancer lower esophageal those
RA chemotherapy. sphincter pheochro,ocytoma or
tone, and block >Urge patient to report
dopamine seizure disorders. persistent or serious
>To prevent or receptors at the Also contraindicated
reduce trigger zone. in those for adverse effect promptly.
postoperative whom stimulation of
nausea and GI motility
might be dangerous >Adice patient to aviod alcohol
vomiting (ex. Those ingestion during
>To facilitate small- with hemorrhage,
bowel obstruction or therapy.
intubation, to aid in >When oral solution is used
radiologic perforation. dilute in pudding,
applesauce juice or water just
examinations. before using.