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Medical Abstract

 Essay about Medical Abstract

REMEDIOS TRINIDAD ROMUALDEZ HOSPITAL

CALANIPAWAN STREET, TACLOBAN CITY

June 23, 2012

MEDICAL ABSTRACT

A case of Martinez, Socorro S., 70 years old, female, hitched, Filipino, Both roman Catholic, a resident of Brgy. 96 Calanipawan, Tacloban City, was admitted at RTRH for the second time on June 15, 2012 around six: 20 are with a primary complaint of difficulty of breathing.

Patient's condition began 5 days and nights prior to admission, when your woman had immediate onset of fever. She took Alaxan five-hundred mg tabs once. There was no additional associated indications noted including cough, the common cold, chest pain, and dyspnea. Zero consultation was done.

3 days just before admission, fever persisted and was now associated with human body malaise. She took Paracetamol 500 mg tab when which provided temporary comfort. Night prior to admission, symptoms persisted and was now associated with problems of inhaling and exhaling. Persistence of symptoms prompted patient to get consult, therefore the admission. She is a known hypertensive for six years with unrecalled maintenance medicine. She has family history and ancestors of Heart disease on familiar side. She actually is a Brgy. Kagawad, a nonsmoker and non-alcoholic drink drinker. She gets no well-known allergies to food and medicines.

Upon entrance, she was examined mindful, coherent, while using following vital sings of BP 160/90 mmHg, HUMAN RESOURCES 81 bpm, RR twenty-five cpm and temperature of 37. your five C. Significant physical conclusions include (+) tight breathing passages, (+) rales, (+) infrequent wheeze. O2 inhalation by way of nasal cannula at three to four L/min was handed. Venoclysis of PLR you L in 20 gtts/min was began. She was on total low salt, low fat diet plan. Diagnostics were requested just like CXR PENNSYLVANIA which revealed Bronchitis, CBC which showed elevated WBC of 12-15. 45 with predominance of Neutrophils zero. 77. Urinalysis was mild yellow, somewhat turbid, RBC of 4-6/hpf and Marcia Cells of 5-10/hpf. Medications were prescribed such as Salbutamol + Ipratropium nebulization Queen 6 H, Hydrocortisone 200 mg IVTT Q 6th H, Procaterol 25 mcg...

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