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Reason/s for Seeking Health Care: Pricking to crampy epigastric pain radiating to the
back & both flanks and nausea
Primary Attending Physician: Dr. Timonera
Consultants/Specialists: Dr. Debalucos, Daroy, Marquez, Sumndad
Initial Impression/Diagnosis: Acute gastritis
Final Diagnosis: 1. Obstructive jaundice secondary to
choledocholelithiasis
Entrero-Gallbladder fistula
2. Incision & Drainage of subcutaneous abscess
3. Acute Pancreatitis
4. Hypertensive stage 2
5. Ischemic Heart Disease
6. Aortic Stenosis
7. Bronchial asthma with acute exacerbation
8. Diabetes Mellitus Type 2
7
Description of the patient: Patient is conscious, coherent, oriented and conversant but
is sometimes irritated. No in respiratory distress and was
afebrile during our shift. With Jackson Pratt drainage at
right upper quadrant, surgical wound was tender, reddish
and with minimal pus upon inspection. Urinary catheter
was attached and patient wears diaper. IVF of PNSS @
20gtts/min is inserted at right dorsum hand. Good hygiene
was observed.
NURSING HISTORY
stage 2, community acquired pneumonia-lower risk and urinary tract infection. Last month, she
had an operation for cataract at left eye.
Patient secret is hypertensive since 2 years ago, having a blood pressure ranging between
of 170/100 - 140/100 and is a known diabetic for 3 years.
Secret is compliant to her maintenance medications which are Aspirin 80mg, metformin
500mg, linagliptin 5mg, Kremil-S, Amlodipine 5mg, Atorvastatin 40mg, Pantoprazole 40mg,
Trimetazidine 35mg and Candesartan 8mg. she takes montelukast 10mg if she is manifesting
difficulty of breathing and Kremil-S to provide relief for flatulence and gas pain.
She has no known allergy to medications, food and as well as latex.