Name of Patient: MASANGKAY, GERTRUDES JOSON

Informant: Patient & Granddaughter

Reliability: Fair
Group no.: 3
Historian: Rivera, Kevin N.

Hospital: DLSUMC
Department: Internal Medicine
Attending Physician: Dr. Salvador
Date Admitted: November 12, 2016
Date Taken: November 19, 2016

OFF-SERVICE NOTES
S>
General Data
G.M., a 85 year-old, female, married, Filipino, Christian, born on November 3, 1931 at Manila and is
currently residing at General Trias, Cavite, was admitted for the first time at DLSUMC around 5:00 PM .
Chief Complaint
Body weakness
History of Present Illness
The patient was apparently well until one week prior to admission when patient experienced
generalized body weakness, nausea accompanied with loss of appetite. There were no associated laterality of
weakness, slurring of speech, headache, diaphoresis, seizure, diarrhea and vomiting. No consult was done
and no medications were taken.
Three days prior to admission, patient symptoms persisted accompanied with difficulty of breathing.
There were no associated cough, chest pain, fever, chills, vomiting, dizziness, headache and numbness. No
consult done, no medications were taken.
On the day of admission, patient symptoms persisted such as body weakness, loss of appetite, unable
to stand still and nausea which prompted them consult and subsequent admission.
Past Medical History
The patient was known hypertensive. She was hospitalized in 2010 due to hypertensive urgency. Her
maintenance medications were Tramadol+Paracetamol 37.5/325mg PRN for pain, Furosemide 40mg tablet
OD, Trimetazidine 35mg BID, Amlodipine 5mg OD, Spironalactone 50mg OD, Carvedilol 20mg OD, Dabigatran
150mg cap ODHS and Atorvastatin 10mg ODHS. She had open cholecystectomy in 2009. No previous
accidents noted. No known allergies to food and medications.
Family History
No family history of hypertension, diabetes, asthma, CVA, malignancy, hematologic, endocrine and
PTB noted.
Personal and Social History
She is a non-smoker, non-alcoholic drinker. She has no history of illicit drug use.
Obstetric History
The patients age of menarche is at 15 years old. She was 55 years old at menopause. Her OB score
was G10 P10 (10-0-0-7).
> Patient is currently on her seventh hospital day. Patient complains of dysuria at times. No nausea, vomiting
and loss of appetite noted.
Problem 1: dysuria
Problem 2: hypocalcemia
Problem 3: hypertension
Problem 4: bowel movement
O> V/S BP: 120/80 mmHg PR:86 bpm RR:17 cpm T: 36.4
General: awake, conscious and coherent and appears not in cardiorespiratory distress
Skin: (-) pallor, (-) jaundice, good skin turgor, (-) lesions
Head: normocephalic, (-) deformities, (-) cervical lymphadenopathies
Eyes: symmetrical, pupils 2-3 mm EBRTL, anicteric sclera

Ears: (-) deformities, (-) lesion

Nose: (-) alar flaring, nose symmetrical
Throat: pink and moist oral mucosa, tonsils not hyperemic, not enlarged and not exudative
Chest and Lungs: symmetrical chest expansion, no adventitious breath sounds noted
Heart: (-) precordial bulging, (-) heaves and thrills, irregularly irregular rhythm, no murmurs
Abdomen: slightly globular, (+) horizontal surgical scar on Right Upper Quadrant, symmetrical, (-) lesions,
normoactive bowel sounds, soft, (-) direct tenderness
Extremities: full and equal peripheral pulses,(-) atrophy, (-) edema, (-) joint tenderness
Neuro:
CN I: not assessed
CN II (+) direct and consensual reflex
CN III, IV, VI Full EOMs
CN V good masseter tone
CN VII (+) facial asymmetry, shallow left nasolabial fold
CN VIII - decrease hearing
CN IX, X able to swallow
CN XI good SCM and trapezius tone
CN XII tongue in midline, no fasciculations
Sensory:
100%|100%
100%|100%
Motor:
4/5 | 4/5
5/5 | 5/5
Laboratory:
URINE CULTURE & SENSITIVITY (11/16/2016)
Organism: Escherichia coli, ESBL positive, 100,000 CFU/ML
Resistant: Ampicillin, Piperacilin Tazobactam, Ceftriaxone, Cefuroxime,Trimethoprim/Sulfamethoxazole, Cefuroxime
axetil, Amoxicillin/Clavulanic acid, Cefepime, Ceftazidime, Ciprofloxacin
Sensitive: Ertapenem, Meropenem, Amikacin, Cefoxitin, Imipenem, Gentamicin,Colistin
URINALYSIS
Color
Character
SG
pH
Albumin
Sugar
WBC
RBC
Bacteria
Epithelial Cells
Mucus threads

11/14
Yellow
Cloudy
1.015
5.0
Trace
Negative
18-20/HPF
1-2/HPF
+3
Few

11//16
Light yellow
Cloudy
1.015
6.0
Trace
Negative
45-50/HPF
1-2/HPF
+3

11/18
Yellow
Slightly Cloudy
1.010
6.0
Trace
Negative
40-45/HPF
0-2/HPF
Few
Few
Few

A> Complicated Urinary Tract Infection secondary to ESBL positive Escherichia coli; Multiple Electrolyte
Imbalance, Hypocalcemia, Hyponatremia and Hyperkalemia, Resolving; Chronic Atrial Fibrillation in Controlled
Ventricular Response; Hypertension, Controlled

P>
Problem 1: Dysuria
Give Ertapenem 1g IV OD to treat the microorganism that caused the complicated UTI.
Repeat Urinalysis on Sunday.
Problem 2: Hypocalcemia
Give Calcium supplement to treat hypocalcemia.
Problem 3: Hypertension
Amlodipine 5mg/tablet. 1 tablet OD in the morning for hypertension.
Problem 4: Bowel movement
Withhold Lactulose and re-assess bowel movement daily.