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    Patient Report

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    Cyrille Aira Andresa
    This document contains biographical and medical information for a 51-year-old male patient who presented with a 2-day history of squeezing abdominal pain. His medical history includes diabetes for 6 years and a recent hospitalization for diarrhea. Physical exam revealed an ill-looking patient with elevated blood pressure and abnormal lab results including high blood glucose, hemoglobin A1C, and liver enzymes. He was diagnosed with acute urinary retention.

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    Patient Report

    Uploaded by

    Cyrille Aira Andresa
    4 views5 pages
    This document contains biographical and medical information for a 51-year-old male patient who presented with a 2-day history of squeezing abdominal pain. His medical history includes diabetes for 6 years and a recent hospitalization for diarrhea. Physical exam revealed an ill-looking patient with elevated blood pressure and abnormal lab results including high blood glucose, hemoglobin A1C, and liver enzymes. He was diagnosed with acute urinary retention.

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    This document contains biographical and medical information for a 51-year-old male patient who presented with a 2-day history of squeezing abdominal pain. His medical history includes diabetes for 6 years and a recent hospitalization for diarrhea. Physical exam revealed an ill-looking patient with elevated blood pressure and abnormal lab results including high blood glucose, hemoglobin A1C, and liver enzymes. He was diagnosed with acute urinary retention.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    4 views5 pages

    Patient Report

    Uploaded by

    Cyrille Aira Andresa
    This document contains biographical and medical information for a 51-year-old male patient who presented with a 2-day history of squeezing abdominal pain. His medical history includes diabetes for 6 years and a recent hospitalization for diarrhea. Physical exam revealed an ill-looking patient with elevated blood pressure and abnormal lab results including high blood glucose, hemoglobin A1C, and liver enzymes. He was diagnosed with acute urinary retention.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    CALAMBA DOCTORS’ COLLEGE

    Virborough Subdivision, Parian, Calamba City, Laguna


    COLLEGE OF NURSING
    John Mikelangelo V. Andon
    BSN2A
    BIOGRAPHICAL INFORMATION

    Name: De Lara, Rafael Supan


    Age: 51 years old
    Gender: Male
    Weight:
    Marital status:
    Religion: Catholic
    Attending Physician: Dr. Roa, Dra. Hernandez, Dra, Quing, Dr. Malabanan
    Impression: A urinary retention, 2 to BPH, DM2 uncontrolled w/complication -SP explore LAP AP for
    ruptured w/adhesiolysis.

    REASON FOR SEEKING HEALTHCARE


    The chief complain of the patient is 2 days hypogastric of squeezing pain.

    HISTORY OF PRESENT HEALTH CONCERN (COLDSPA)

    CHARACTER: 2 days of squeezing pain in abdomen


    ONSET: 4 weeks ago
    LOCATION: Stomach
    DURATION: It does recur
    SEVERITY: None tolerable. The pain scale of the patient is 10/10
    PATTERN: -
    ASSOCIATED FACTORS: Diabetes (6 years)
    Age over 50.
    Unhealthy Lifestyle (Alcoholism)

    PERSONAL HEALTH HISTORY:


    As per the patient daughter stated during the interview, he does have diabetes for 6 years.
    PAST HEALTH HISTORY:
    The patient consulted to private institution where the patient experience 4 episodes of LBM.

    FAMILY HISTORY:
    According to the patient daughter, they do not have anyone on the family that have the same
    illness as the patient has.
    SOCIAL HISTORY:
    -
    MEDICATION
    Oral Medication:
    8/31/23- 9:00pm
     Tamsulosin 400 mcg 1 cup
    11:00pm
     IV/BLOOD/PLASMA
     #15 PLR 1 L x 16hrs
     Tramadol Paracetamol 1 tab
     PRN for pain
    9/01/23- 4:00pm
     IV/BLOOD/PLASMA
     #16 PLR 1L X KVO
    8:00am
     Vitamin B complex 1-tab B10
     HRZE 150/75/400/ 275, 4 tabs OD past BF
    8:00am-6:00pm
     Transmert 500mg/tab
     1 tab B10
    IV MEDICATION:
    8:00pm-4:00am-12:00pm
     PIPTAZ (VIGOCID) 4.5 GRAMS
     IV drip Q8 (-) ANST
    6:00am
     Omeprazole 40 mg IV OD
     Paracetamol 600 mg IV
     Q4 PRN
     T > 37.9
    8:00pm-4:00am-12:00pm
     Tramadol 100 mg IV
     SIVP
     Q8
    10:00pm
     Insulin Glargine 12 “v”
     SQ
    PHYSICAL EXAMINATION:
    General Appearance:
     Level of Consciousness: Fully conscious
     Orientation: Well oriented
     Activity: Limitation of physical activity but in normal behavior
    Anthropometric Measurement:
     Weight: -
    Vital Signs:
     Temperature: 36.6c
     Pulse rate: 103
     Respiratory rate: 22
     O2sat: 99%
     Blood pressure: 140/ 100
    Head:
     Hair: Thin
     Color of hair: Black
     Scalp: -
     Pediculosis: -
    Face:
     Face: ill looking
     Facial puffiness: none
    Eyes:
     Eye brows: Well balanced
     Eyelids/lashes: Normal
     Eyeball: normal
     Conjunctiva: -
     Sclera: reddish in color
     Puncta: -
     Cornea: -
     Iris: Dark brown
     Pupil: -
    Nose:
     Nasal septum: -
     Nasal cavity: -
     Nasal discharge: -
    Lips:
     Crack/Healthy: Dry lips
     Cleft lips: None
     Stomatitis: None
    Ears:
     Shape: Roung ear shape
     Redness: No earache
     Discharge: -
     Cerumen: -
     Lesions: None
     Foreign body: No foreign body
     Use of hearing aids: None
     Tuning fork test: -
     Weber test: -
     Rinne test: -
    LABOLATORY TEST:
    Test Result Range reference
    SGOT/AST 28.3 40
    Hemoglobin A1C High 8.9 4.3-6.4
    Creatine enz 1.0 0.66-1.22
    Blood Urea Nitrogen 17.6 7-18
    SGPT/ALT High 59.4 <41.6
    Sodium Low 133.2 135-145
    Potassium 3.94 3.5- 5.3
    Glucose, RBS High 295 70-152

    DIAGNOSTIC:
    Acute urinary retention.

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