Admitting History
This is a case of Jose Sixto Mendoza III, a 45-year-old male, single, Filipino, Catholic
and a resident of San Gerardo Heights, Tacloban City. He was brought to the ER
Department last October 16, 2020 due to dizziness and vomiting.
Condition of patient started approximately 2 days PTA, when he started experiencing
waxing and waning episodes of dizziness while playing golf with a client. He attributed
the symptom to staying out too long under the sun and just opted to rest and hydrate
himself by increasing his water intake which seemed to afford relief. No medications
were taken and no consultation was done.
A day PTA after lunch, he noted sudden onset of nape pains with pain scale 7/10
associated with dizziness and nausea. Patient took in Mefenamic acid 500mg capsule
and took a nap. When he woke up his symptoms has ebbed and nape pain was now at
3/10.
About 3 hours PTA, over lunch with a client, nape pain, dizziness and nausea recurred.
He took in again a Mefenamic acid 500mg capsule. Symptoms decreased but did not
resolve. Patient decided to go home to rest after his meeting.
While driving home, symptoms increased in severity and he vomited thrice to previously
ingested food. This prompted patient to drive to the ER, to seek consult, hence this
admission.
Medical/Family/Psychosocial History
Patient is a non-hypertensive but recalls episodes of BP elevations with highest
recorded SBP 150mmHg for the past year for which no consult was done. He is a non-
diabetic and non-asthmatic with no known food and drug allergy. He negates of any
previous hospitalizations, operations and claims that previous medical check-ups
needed for work were otherwise unremarkable.
Family history is very strongly heredofamilial for Hypertension and Type 2 Diabetes on
both sides.
He was recently promoted as district manager for a pharmaceutical company. A smoker
of 7 pack years and a moderate alcoholic beverage drinker. Patient usually eats out 2-3
days a week due to his work (entertaining clients) and does not adhere to any exercise
regimen. Average sleeping time is 4-6 hours per day in the past year due to his hectic
schedule.
Physical Examination
Patient was seen and examined at the ER, conscious, coherent, not in respiratory
distress with the following vital signs:
BP= 180/100 mmHg HR= 110 bpm RR= 24 cpm
T= 37.0ºC O2 sat= 98% (room air) CBG= 145 mg%
Skin: flushed skin with good turgor, no lesions, no hypo/hyperpigmentation, good
capillary refill
EENT: pinkish palpebral conjunctivae, anicteric sclerae, no NAD, no CLAD
C/L: symmetrical, no intercostal and subcostal retractions, harsh breath sounds
Heart: adynamic precordium, tachycardic, heart rate synchronous with pulse rate, no
murmur
Abdomen: full, soft, non-tender, NABS
Extremities: symmetrical, full pulses, no cyanosis, no edema
Neurologic: no focal deficit at the time of examination
Admission
Date & Time Admitting Orders
10/16/2020 > Please admit to room of choice
09:00 PM > Secure consent for admission and management
T= 37.0ºC > TPR q shift
PR= 110 bpm > NPO temporarily except meds
RR= 24 cpm Problem: dizziness & vomiting
BP= 180/100 > Diagnostics:
mmHg o 12 lead ECG
O2 sat= 98% o CXR PA view
CBG= 145mg% o FBS, lipid profile, BUA, SGPT in AM
o BUN, Creatinine
o Na, K, Calcium
o CBC
o Urinalysis
> Furosemide 40mg IVTT stat
> Start IVF with PLR 1L at 30 gtts/min
>Medications:
1. Nicardipine 2mg IVTT now, repeat BP after 30 minutes & refer
2. Metoclopramide 10mg slow IVTT now
3. Omeprazole 40mg IVTT now, then OD
> Monitor I & O q shift
> Refer for untoward manifestations
> Refer accordingly
Course in the Wards
ANCILLARY
PROCEDURE 1. 12 lead ECG
AND
LABORATORY
RESULTS
2. Blood Chemistry
Parameter Result Normal Value
Blood Urea 4.0 2.5 – 6.5 mmol/L
Nitrogen
Creatinine 105 65 – 105 umol/L
Calcium 2.55 2.10 – 2.55 mmol/L
Sodium 145 135 – 145 mmol/L
Potassium 4.95 3.5 – 5.5 mmol/L
3. CBC
Parameter Result Normal Value
Hemoglobin 185 130 – 170 g/L
Hematocrit 0.58 0.41 – 0.50
WBC count 10.0 5.0 – 10.0 x 109/L
Segmenters 0.70 0.55 – 0.65
Lymphocytes 0.30 0.25 – 0.35
4. Urinalysis
Parameter Result
Color Yellow
Transparency Slightly turbid
pH 6.0
Specific gravity 1.010
Protein Trace
Sugar (-)
Pus cells 0-1/hpf
Red blood cells 0-1/hpf
Epithelial cells Few
Bacteria Few
Amorphous urates Few
Mucus threads Few
09:40 PM > Start Nicardipine drip: Nicardipine 10mg + PNSS 90cc per soluset
BP= 190/120 initially regulated at 16 cc/hr. Uptitrate by 2 cc q 30 minutes and maintain
mmHg rate once MAP is reached (NO TARGET MAP) CLARIFY
MAP= 140 > Cinnarizine 75mg cap now, then OD
PR= 105 bpm > Aspirin 80mg tab now, then OD pc breakfast
(+) dizziness > Please get weight and height once can tolerate ambulation
(+) LVH w/ LV > Refer accordingly
strain per ECG
Date & Time 1st Hospital Day
10/17/2020 > May have full low salt, low fat diet
08:15 AM > IVF to follow: PLR 1L at same rate
BP= 140/90 > Follow-up laboratory results
mmHg > Nicardipine drip to consume
PR= 92 bpm > Start Telmisartan 80mg tab OD to start tomorrow at 6AM
Wt= 78 kg > Continue other medications
Ht= 168 cm > Refer to Ophthalmology for fundoscopy
BMI= 28 > BP monitoring q 4H (if awake)
(+) dizziness, > Refer accordingly
mild
ANCILLARY
PROCEDURE 1. CXR PA view
AND - Normal chest findings
LABORATORY
RESULTS
2. Blood Chemistry
Parameter Result Normal Value
FBS 6.8 3.89 – 5.83 mmol/L
Total cholesterol 7.2 1.0 – 5.2 mmol/L
HDL cholesterol 1.9 0.93 – 1.56 mmol/L
LDL cholesterol 5.8 0.0 – 2.59 mmol/L
Triglyceride 2.5 0.0 – 1.7 mmol/L
Blood uric acid 555 180 – 400 umol/L
SGPT 132 1.0 – 41.0 U/L
05:00 PM > Revise current diet to computed diet with TCR of 2,400 kcal/day
BP= 160/90 divided into 3 main meals with snacks in between comprised of the
(SBP range: following:
150-170) o CHO – 360 gm/day
PR= 100 bpm o CHON – 90 gm/day
improving o Fats – 67 gm/day
dizziness o limit Na to 2gm/day
> For HbA1c, thyroid panel
Fundoscopy: > IVF to follow: PLR 1L at 20 gtts/min
Normal, OU > Start the following medications:
1. Bisoprolol 5mg tab now, then OD at 6PM
2. Rosuvastatin 20mg tab OD at HS
3. Allopurinol 300mg tab OD pc lunch
4. Silymarin capsule TID
> May discontinue Omeprazole
> Refer accordingly
Date & Time 2nd Hospital Day
10/18/2020 > IVF to consume, then attach to heplock
09:00 AM > Continue medications
BP= 150/90 > For abdominal UTZ include prostate
mmHg > May decrease BP monitoring to q 6H (if awake)
PR= 89 bpm > Refer accordingly
(-) dizziness
LABORATORY 1. Special tests
RESULTS Parameter Result Normal Value
HbA1c 4.8 below 6.0%
T3 1.5 0.92 – 2.33 nmol/L
T4 75 60 – 120 nmol/L
TSH 3.0 0.25 – 5.0 uUI/ml
FT3 5.2 4.0 – 8.3 pmol/L
FT4 15.7 11.0 – 22.1 pmol/L
Date & Time 3rd Hospital Day
10/19/2020 > Continue medications
07:45 AM > Taper BP monitoring to q shift
BP= 140/90 > Refer accordingly
mmHg
(SBP range:
140-160)
PR= 82 bpm
(-) complaint
ANCILLARY
PROCEDURE 1. Abdominal UTZ include prostate
- Unremarkable sonographic findings
Date & Time 4th Hospital Day
10/20/2020 > Kindly bill patient until tomorrow
12:00 NN > Possible discharge in AM if without untoward manifestations and SBP
BP= 120/80 maintained at 90-130 mmHg
mmHg > Home medications:
(SBP range: 1. Telmisartan 80mg tab OD, 6AM
110-130) 2. Bisoprolol 5mg tab OD, 6PM
PR= 79 bpm 3. Aspirin 80mg tab OD pc breakfast
(-) complaint 4. Allopurinol 300mg tab OD pc lunch
5. Rosuvastatin 20mg tab OD, HS
6. Silymarin capsule TID
> Refer to Dietary for meal plan
> Please allow patient to have a copy of all laboratory work-up done
> Refer accordingly
Date & Time 5th Hospital Day
10/21/2020 > Terminate heplock
08:00 AM > May go home
BP= 110/80 > Carry out discharge orders
mmHg > BP monitoring at home twice a day, record please and bring monitoring
PR= 75 bpm on follow-up after 1 week at OPD Dept. Room 143
(-) subjective > Call 0995 448 4400 to set appointment
complaint > Advised
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION
Calanipawan Rd. Tacloban City
COLLEGE OF NURSING
REMEDIOS TRINDIDAD ROMUALDEZ HOSPITAL
NURSES PROGRESS NOTES
DATE/TIME FOCUS D = DATA A = ACTION R = RESPONSE
Oct. 16, 2020 Initial Assessment D: Arrived a 45-year old male via wheelchair, conscious and
9:00 PM (ER) coherent, with chief complaints of increased severity of
nape pain, dizziness, nausea, and vomiting.
-----------------------------
A: Secured consent for management and care, signed by
patient. Ushered to bed and placed in a comfortable
position with side rails raised and locked. Assessed V/S
with the results of: T= 37.0ºC, PR= 110 bpm, RR= 24 cpm,
BP= 180/100 mmHg, O2 sat= 98% at room air, and CBG=
145mg/dL. Examined and admitted by Resident on duty
with the following assessment findings of: flushed skin with
good turgor, good capillary refill, harsh breath sounds,
adynamic precordium, tachycardic, no murmur, no
cyanosis, no edema, and no focal deficit.
------------------------------------------------------
9:05 PM Elevated Blood D: “Masakit it akon tangkugo ngan malipong ha ulo," as
Pressure verbalized. Nape pain rated 7/10 in PRS. Vital signs are as
follows: T= 37.0ºC, PR= 110 bpm, RR= 24 cpm, BP=
180/100 mmHg, O2 sat= 98% at room air. MAP: 140. LVH
with LV strain per ECG. CBG: 145 mg/dL. Other laboratory
exams Hgb = 185 g/dL, Hct = 58%, Segmenters = 70%.
Vomited thrice (quantity, color, profuse) ---------------
A: Maintained in semi-fowler’s position. Maintained bed rest
during acute phase and provided urinal. Instructed
relaxation techniques, such as guided imagery, distraction
and deep breathing. Minimized environmental stressors
such as noise or any stimulus or triggering factor that may
9:10 PM aggravate pain. Loosened restrictive clothing. Provided a
calibrated glass and monitored I&O.
9:15 PM ----------------------------------------
9:20 PM : Started IVF with PLR 1L regulated at 30 gtts/min using
9:23 PM gauge and cannula, site. RIGHT METACARPAL VEIN.
9:26 PM -------
9:30 PM : Administered Furosemide 40mg IVTT.
---------------------------
TIME BP : Administered Nicardipine 2mg IVTT.
RECHECKED ------------------------------
Referred to ER : Administered Metoclopramide 10mg slow IVTT.
ROD ---------------
: Administered Omeprazole 40mg IVTT.
---------------------------
: Started Nicardipine drip: Nicardipine 10mg + PNSS 90cc
per soluset initially regulated at 16 cc/hr. Up titrate by 2 cc q
30 minutes and maintained rate once MAP is reached.
------------
: Administered Cinnarizine 75mg cap now. -----------------------
: Administered Aspirin 80mg tab now.
------------------------------
Continuous monitoring of BP.
R: Reduced dizziness, decreased PR from 105 to 92 bpm,
decreased MAP from 140 to 110, and decreased blood
pressure from 190/120 to 180/120.
----------------------------------
10:30 PM Pre-transfer D: Wheeled to medical ward via wheelchair, awake and
Assessment alert, with an ongoing PLR 1L regulated at 30 gtts/min
infusing well at right metacarpal vein. IV of Nicardipine
10mg + PNSS at level 90cc regulated at 16 cc/hr infusing
well at left metacarpal vein. With the following vital signs: ..
and endorsed to medical ward nurse on duty.
---------------------------------------------------------
TIME(Wheeled) A: Ushered to bed of choice. Placed on a comfortable
and endorse position. Started PLR 1L at level 300 cc regulated at
with vital signs) 30gtts/min. Side rails raised and locked. Oriented with the
ward’s policies and protocols. Followed-up laboratory
results. Referred to Ophthalmology for fundoscopy.
Monitored BP q 4H. Referred accordingly to doctor once
admitted. -------------
GROUP C
1st day
DATE/TIME FOCUS D = DATA A = ACTION R = RESPONSE
Oct. 17, 2020 Elevated Blood D: “Masakit iton akon batok, ngan medyo nalilinop ako
8:15 AM Pressure ma’am,” as verbalized. With ongoing Nicardipine drip of
10mg + PNSS at level 90cc regulated at 26 cc/hr infusing
well at left metacarpal vein. Vital signs are as follows: PR=
92 bpm and BP= 140/90 mmHg. Reported nape pain as
6/10 using Numerical Pain Rating Scale (0-10), mild
dizziness present. MAP: 106.67. Weight: 78 kg, height: 168
cm, BMI: 28, observed sedentary lifestyle, and minimal
1:20 PM physical activity.----------------------------------------------------------
A: Placed in a comfortable position. Monitored vital signs
and I&O. Encouraged bedrest during acute phase, as
indicated. Recommended relaxation techniques, such as
guided imagery and distraction. Loosened restrictive
clothing. Minimized extraneous activities that may aggravate
headache, such as straining at stool, prolonged coughing,
and bending over. Cautioned visitors to avoid sharing of
stressful situation. Discussed necessity for decreased
caloric intake and limited intake of fats, salt, and sugar, as
indicated. Determined desire to lose weight. Reviewed usual
daily caloric intake and dietary choices. Established a
realistic weight reduction plan, such as weight loss of 1
pound per week. Encouraged to maintain a diary of food
intake, including when and where eating takes place and the
circumstances and feelings around which the food was
eaten. Assisted in appropriate food selections, such as
implementing a diet rich in fruits, vegetables, and low salt,
low-fat dairy foods referred to as the Dietary Approaches to
Stop Hypertension (DASH) diet. Referred to dietitian or
3:00 PM weight management programs, as indicated. Assisted with
ambulating, as tolerated. Due medications given as
ordered. --------------------------------------------------------------------
R: “Medyo naibanan an kasakit an akon batok. Diri na
gihapon ako nalilinop”, as verbalized. Reported nape pain as
4/10 using Numerical Pain Rating Scale (0-10). BP: 140/90
mmHg. MAP: 110. Demonstrated change in eating patterns,
such as food choices and quantity, to attain desirable body
weight with optimal maintenance of health. Initiated and
maintained individually appropriate exercise program.---------
2ND DAY
DATE/TIME FOCUS D = DATA A = ACTION R = RESPONSE
10/18/2020 Elevated blood D: “Nawara naman an pag kalipong han akon ulo kakulop,”
09:00 AM pressure as verbalized. Vital signs are as follows BP= 150/90 mmHg.
A: Maintained in a comfortable position with side rails raised
and locked. Monitored vital signs and I&O. Measured BP
taken three readings, 3 to 5 minutes apart while at rest, then
sitting, and then standing for reassessment using correct
cuff size and accurate technique. Auscultated heart tones
and breath sounds. Loosened restrictive clothing. Provided
a calm, restful surroundings, minimized environmental
activity and noise. Cautioned visitors to avoid sharing of
stressful situation. Maintained activity restrictions such as
CBR. Advised to maintain adequate rest periods.
Encouraged deep breathing exercises. Instructed in
relaxation techniques, guided imagery and distractions.
Monitored response to medications that control BP. Due
medications given as ordered. ---------------------------------------
11:30 AM R: Participated in activities that reduce BP and cardiac
workload. Improved cardiac output as evidenced by blood
pressure of 140/90 mmHg. --------------------------------------------
GROUP C
3RD DAY
DATE/TIME FOCUS D = DATA A = ACTION R = RESPONSE
10/19/20 Elevated blood D: BP: 140/90 mmHg (SBP range: 140-160), PR: 82 bpm.
7:45 AM pressure ---
A: Placed in a comfortable position. Monitored vital signs
q4h and I&O. Administered medication as ordered.
Loosened restrictive clothing. Encouraged and maintained
bed rest. Scheduled periods of uninterrupted rest.
Minimized environmental activity and noise by asking
visitors to minimize their voice. Cautioned visitors to avoid
sharing of stressful situation. Limited the number of visitors
(1-2) and length of visitation. Educated patient on stress
management, deep breathing exercises, and relaxation
11:30 AM technique, such as distraction, imagery, and relaxation.
Referred latest monitored bp to the ROD.
---------------------------------------------
R: Decreased blood pressure from 140/90 mmHg to 120/80
mmHg noted.
--------------------------------------------------------------
GROUP C
Knowledge deficit**
4TH DAY
DATE/TIME FOCUS D = DATA A = ACTION R = RESPONSE
October 20, Health teaching D: “Mas maupay na it akon inaabat yana, kontra han akon
2020 regarding control inaabat an siyahan ko nga ka-admit ngadi,” as verbalized.
12:00 NN of disease process BP – 120/80 mmHg, PR – 79 bpm.
--------------------------------------
A: Encouraged gradual smoking cessation. Educated on the
specific signs and symptoms of the current disease and to
monitor reoccurrence of the condition for immediate consult.
Educated on how to monitor vital signs especially taking the
BP. Instructed to Eat more fruits, vegetables, and low-fat
dairy foods, avoid foods that are high in saturated fat,
cholesterol, and trans fats, eat more whole-grain foods, fish,
poultry, and nuts, limit sodium, sweets, sugary drinks, and
red meats. Instructed to drink a lot of noncaffeinated,
nonalcoholic fluids and lessen alcohol intake.
Recommended to exercise regularly. Advised to adhere
medication regimen on Telmisartan 80mg tab once a day to
be taken at 6AM, Bisoprolol 5mg tab once a day to be taken
02:00 P.M. at 6PM, Aspirin 80mg tab once a day to be taken after
breakfast, Allopurinol 300mg tab once a day to be taken
after lunch, Rosuvastatin 20mg tab once a day to be taken
at bed time and Silymarin capsule three times a day.
Provided copy of all laboratory work-up done. Referred to
dietitian accordingly. ----------------------------------------------------
R: “Hihinumdumon ko an akon mga turumaron nga
medisina hit pan-adlaw adlaw.” Arranged medications on a
weekly pill organizer. Demonstrated proper way of administering
medications. Enumerated suggested foods by the dietitian. Verbalized
health teachings imparted. -----------------------------
GROUP C
5th day
DATE/TIME FOCUS D = DATA A = ACTION R = RESPONSE
October 20, Discharge D: “Maupay na an akon pamati. Diri na ako nalilipngaw,” as
2020 Planning verbalized. With discharge order.
08:00 AM ------------------------------------
A: Assessed current health condition. Vital signs taken and
recorded as follows: T-37˚C, RR-16 cpm, PR-75 bpm, BP-
110/80 mmHg. Heplock removed aseptically as ordered
without ill effect. Encouraged to adhere home medications
prescribed to ensure optimum recovery. Provided a clean
and stress-free environment. Encouraged to get at least 7
hours of sleep each night and take 20-30 minutes rest
periods twice a day and moderate physical activity on most
days of the week for at least 30 minutes. Provide patient and
relative written and verbal information regarding the
following: Importance and side effects of medications given.
Monitor and record blood pressure twice a day. Educated all
about the signs and symptoms. Chest pain or shortness of
breath, moderate to severe headache, Weakness in the
muscles of your face, arms, or legs, trouble speaking,
Extreme drowsiness, confusion, fainting or dizziness, Blood
pressure measured at home that is greater than 120/80.
Instructed to continue follow-up after a week upon discharge
at EVRMC OPD department, Room 143. Instructed to call
0995 448 4400 to set appointment beforehand. Advised a
09:00 AM low salt and low-fat diet. Advised to limit caffeine intake.
Encouraged to pray and strengthen faith in God.
------------------------------------------
R: “Salamat, ma’am. Igsusurat ko nala po an akon BP kada
adlaw ngan babasahon nala liwat namon utro ini nga mga
papel kun mahingalimot man ako han mga tugon ha akon,”
as verbalized. Wheeled out of the room per wheelchair with
improved condition accompanied by brother.
---------------------
GROUP C
Hygiene, diet (low salt, low fat, high roughage diet), demonstration and return
demonstration BP-taking (patient and significant others)**, digital bp apparatus
MONITORING SHEET (Target MAP = 140)
DATE AND TIME BLOOD MEAN Ongoing Nicardipine Drip
PRESSURE ARTERIAL (cc/hr)
(mmHg) PRESSURE
10/16/2020 180/100 126.67 2 mg IVTT
09:00 PM
09:30 PM 190/120 16
10:00 PM 190/120 18
10:30 PM 180/120 20
11:00 PM 180/100 22
11:30 PM 170/100 24
12:00 AM 170/90 26
12:30 AM 170/90 28
01:00 AM 160/90 30
01:30 AM 160/90 32
02:00 AM 150/90 36
02:30 AM 150/90 38
03:00 AM 140/90 40
03:30 AM 140/90 40
04:00 AM 140/90 40
04:30 AM 140/90 40
05:00 AM 140/90 40
10/17/2020 140/90 40
08:15 AM
08:45 AM 140/90 40
09:15 AM 140/90 40
09:45 AM 140/90 40
10:15 AM 140/90 40
10:45 AM 140/90 40
11:15 AM 140/90 40
11:45 AM 140/90 40
12:15 PM 140/90 40
12:45 PM 140/90 40
01:15 PM 140/90 40
01:45 PM 140/90 40
02:15 PM 150/90 42
02:45 PM 150/90 44
03:15 PM 150/90 46
03:45 PM 150/90 48
04:15 PM 160/90 50
05:00 PM – 7:00PM 160/90 52
10/18/2020 150/90 54
Insert 7 - 09:00 AM
09:30 AM 150/90 56
10:00 AM 150/90 58
10:30 AM 150/90 60
11:00 AM 150/90 62
11:30 AM 140/90 62
12:00 NN 140/90 62
12:30 PM 140/90 62
01:00 PM 140/90 62
01:30 PM 140/90 62
02:00 PM 140/90 62
02:30 PM 140/90 62
03:00 PM 140/90 62
03:30 PM 140/90 62
04:00 PM 140/90 62
04:30 PM 140/90 62
05:00 PM 140/90 62
10/19/2020 140/90 -
07:45 AM
