Karen Grace V.

Roque CLDH-SCU

Narrative Report A patient at St. Camillus Ward named Mr. Primitivo Dupitas, 69 year old who was confined on July 12, 2011 with a chief complaint of melena and epigastric pain. According to his chart, one day prior to admission, the patient experienced black tarry stool twice associated with epigastric pain and body weakness. During his admission some diagnostic test are given such as Complete Blood Count (CBC) and Esophagealgastroduodenoscopy (EGD) were done. According to the patient, he wanted to go home already. Unfortunately, the attending physician Dr. Nicasio Dizon mentiones that results of the diagnostic test should be seen first to know if further assessment is needed. During the shift the patient has medications of Mucosta 100g 1 tab TID, Omepron 40 mg IVP q12 and a stable vital signs of 130/90 of BP, 26 of RR, 36 of Temperature and 63 of CR. The patient mentioned that the abdominal pain he feels has already decreased and he rated a pain scale of 1/10. After the rounds of his physician, new orders were given such as clear liquid diet was advised, blood transfusion of 3 more units of PRBC type B+ .

Starr Rose E. Basangan CLDH-SCU

Narrative Report Mr. Primitivo Dupitas, a 69 years old male and was residing at Gerona, Tarlac. He has a chief complaint of melena and epigastric pain and was admitted at Central Luzon Doctors Hospital on July 12, 2011 at the afternoon. During his admission the attending physician Dr. Nicasio Dizon ordered Complete Blood Count (CBC) and the results were RBC: 1.79, Hgb: 5.5, Hct: 165 and PLT: 152. And they found out that there are deviations and the physician ordered Blood Transfusion of 2 units of Fresh Whole Blood type B+. The patient has also undergone Esophagealgastroduodenoscopy (EGD) for visualization of the patients GIT and diagnostic purposes. The patient was prescribed to take medications such as Mucosta 100g 1 tab TID and Omepron 40mg IVP every 12 hours. His vital signs were stable with a BP: 130/90, CR: 63, RR: 26 and Temp: 36. He also mentioned that the epigastric pain has subsided with a pain scale of 1/10. On July 13, 2011 at 9:11 am his CBC revealed a result of RBC: 2.23, Hgb: 6.7, Hct: 200 and PLT: 140. Then, around 10:48 am he was seen by his attending physician and made new orders such as Blood transfusion of 3 units of PRBC type B+ properly cross matched and advised clear liquid diet.