January 04, 2011(7:00 p.

m)

Mrs. Purisima Cruz was admitted last January 04, 2011, 3:40 pm at Governor Roque B. Ablan Sr.
Memorial Hospital (GRBASMH), with a chief complaint of pain at right hip with an admitting diagnosis of
fracture femoral neck right by Dr. Rolando Agustin. She was ordered NPO for at least 8 hours because
the patient is for Blood Chemistry Test and ordered for CXR, ECG, BUN, Creatine, Na, K, referred to Dr.
Bolusan.

This was our first contact with our patient at 7:00 p.m. She was lying on bed with an IVF of PNSS
1L at 800 cc level regulated to KVO(10 gtts/min) connected to right dorsum, infusing well, with pain at
the right femoral area as manifested by grimacing face and guarding behavior. And an intact IFC
connected to a urine bag draining to an amber colored urine. Has 10 lbs, skin traction applied.

Vital signs taken as follows:

Body temp: 36.2 C

BP: 110/80 mmhg

PR: 68 bpm

RR: 20 bpm

January 05, 2011(4:05 p.m)

She was lying on bed, weak in appearance, with an IVF of PNSS 1L @ 100 cc level regulated to 20
gtts/min, infusing well. With an intact IFC connected to urine bag draining yellow colored urine and a
skin traction at right leg.

Vital signs as follows:

Body temp: 37.2C

BP: 120/80 mmhg

PR: 79 bpm

RR: 20 bpm
January 06, 2011(4:15 p.m)
She has seen lying on bed, with an IVF of PNSS 1L @ 200 cc level regulated to KVO(10 gtts/min)
connected to right dorsum, with skin traction @ right leg supported with elastic bandage. An intact IFC
connected to urine bag draining to yellow colored urine. She was weak in appearance and with a
complaints of bearable pain @ femur and discomfort and has a high respiratory rate.

Vital signs as follows:

Body temp: 36.3C

BP: 150/100 mmhg
RR: 38 bpm
PR: 86 bpm

January 07, 2011(4:15 p.m)

On this day she was lying on bed, weak in appearance with an IVF of PNSS 1L @ 600 cc level
regulated to 25 gtts/min connected to right dorsum, with skin traction at right leg. An intact IFC
connected to urine bag draining to a yellow colored amber. She has a complaint of post traumatic pain .
Seen and examined by Dr. Agustin during the rounds.

Vital signs as follows:

Body temp: 36.4C
BP: 130/100 mmhg
PR: 80 bpm
RR:20 bpm

January 08, 2011(4:15 p.m)

On this day she was lying on bed, weak in appearance, with an IVF of PNSS 1L @ full level
regulated to 25 gtts/min,infusing well. An intact IFC connected draining to a yellow colored urine, with
skin traction and has a chief complaints of post traumatic pain and discomfort. Seen by Dr. Benjamin
Flor during the rounds.

Vital signs as follows:

Body temp: 37C

BP: 110/80 mmhg

PR: 82 bpm

RR: 20 bpm
January 09, 2011(4:15 p.m)

On this day patient was lying on bed, weak in appearance, with an IVF of PNSS 1L @ 800 cc level
regulated to 21 gtts/min. With a side drip of PNSS 100 ml + 15 u antrapid at micro gtts/min. An intact
IFC connected draining to a yellow colored urine, with skin traction at the right lower extremity. RBS
monitor referred to Dr. Agustin.

Vital signs as follows:

Body temp:36.6C

BP: 90/60 mmhg

PR: 62 bpm

RR: 20 bpm

January 10, 2011(4:20)

On this day patient seen lying on bed, weak in appearance, with an IVF of PNSS 1L @ 100 cc level
regulated to 20 gtts/min, with an insulin drip to 20 micro gtts/min. An intact IFC connected to urine bag
draining well.

Vital signs as follows:

Body temp: 36.2C

BP: 90/60 mmhg

PR: 65 bpm

RR: 21 bpm

January 11, 2011(4:15 p.m)

Seen patient in low fowlers position, weak in appearance, with an IVF of PNSS 1L @ 900cc level
regulated to 20 gtts/min, intact at the right dorsum of her right hand. With an IFC intact connected to
urine bag draining well. With oxygen inhalation via nasal canulla regulated to LPM.

Vital signs as follows:

Body temp: 36.1C

BP: 110/80 mmhg

 PR: 68 bpm

RR: 20 bpm

January 12, 2011(5:15 p.m)

Seen patient lying on bed, weak in appearance, with an IVF of D5W 500 cc @ 400 cc level
regulated to KVO (5 gtts/min), side drip closed. She has an intact IfC connected to urine bag draining to
an amber colored urine.

Vital signs as follows:

Body temp: 36.2C

BP:110/80 mmhg

PR: 68bpm

RR: 20bpm

January 13, 2011(4:20 p.m)

Seen patient in low fowlers position, fair in appearance, with an IVF of D5W 500 cc @ 300 cc
level regulated to KVO(5 gtts/min).

Vital signs as follows:

Body temp: 36.8C

BP: 120/90 mmhg

PR: 75 bpm

RR: 23bpm

January 14, 2011(12:30 p.m)

On the last day of our appraisal, she was seen lying on bed, fair in appearance. There were no
complaint made. She was seen by Dr. Rolando Agustin and ordered mgh at around 3:30 pm, she was
discharged accompanied by relatives. The patient went home with take home medication such as
Mefenamic acid 500 mg
Vital signs as follows:

Body temp: 37.1C

BP: 110/80 mmhg

PR: 78 bpm

RR: 20 bpm