Patient B Was Rushed To Northern Mindanao Medical Center Emergency Due To Chest Tightness

Nursing Health History A. Biological Data Patient B was a 46 years old Filipino, female, was born on November 07, 1966 and residing at Lapasan, Cagayan de Oro City. Her religion is Roman Catholic. She is married and living with her family and has three children. She was admitted for the first at Northern Mindanao Medical Center under doctor Flores as her admitting physician with the diagnosis of chronic kidney disease stage 5 secondary to diabetes mellitus, nepropathy. B. Chief Complaint Patient B was rushed to Northern Mindanao Medical Center Emergency due to chest tightness. C. History of Present Illness Three months prior on admission, patient experienced onset of bipedal edema with easy fatigability and early signs of periorbital edema. A month before admission, there was progression of edema on the thighs and signs of right eye blurring of vision. On the third week prior to admission, patient experienced exertional dyspnea and blurring of vision on the left eye. Patient sought consultation at City Hospital and was given Furosemide. D. Past Health History Patient had no past health history since it was her first time to be admitted in Northern Mindanao Medical Center. E. Functional Health Pattern Upon assessment, patient was in pain, restless and complained of loss of vision. Patient had non pitting bipedal edema, dyspnea even at rest. Because of this, patient had been irritable during assessment gave us small informations about her. She was a non drug user and non alcoholic drinker. Patient b has a history of hypertension and diabetes mellitus on maternal side. F. Nutritional and Metabolic Pattern Patient B’s usual daily food intake before admission was 2 cups of rice and viand with a fluid intake of 3-5 glass of water a total of 720 mL every day. Upon admission, patient B was ordered…

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Patient Was Apparently Well One Week Ago When He Had Episodes Of Seizure At Home Following With Vomiting

  BIODATA OF PATIENT:- NAME- PAUL RAHI AGE- 34 YEARS SEX- MALE UNIT NO.- C- 7385124 WARD- 16 EDUCATION- GRADUATION OCCUPATION- LAB TECHNICIAN MARIETAL STATUS- MARRIED RELIGION- CHRISTIAN DIAGNOSIS- ALCOHOL DEPENDENCE DATE OF ADMISSION- 11-6-12 DOCTOR INCHARGE- DR. SANDEEP GOYAL CHIEF COMPLAINTS:- 34yr. Old Paul Rahi brought to hospital with chief complaints of:- EPISODES OF SEIZURES since one day PALPITATION since one day RETROSTERNAL PAIN since 6days UNEASINESS since 1 week MULTIPLE EPISODES OF VOMITING since one day TREMORS since 2 weeks PRESENT HISTORY:- patient was apparently well one week ago when he had episodes of seizure at home following with vomiting. The patient was brought to casuality. Patient was admitted in ward 23 then was transferred to ward 11 and then was reffered to psychiatric ward. PAST HISTORY:- MEDICAL HISTORY:- No significant past medical history of DM, HTN, TB etc. SURGICAL HISTORY:- No significant history of accident and trauma in past PSYCHIATRY HISTORY:- Patient was drinking alcohol since 10yrs but start taking more since 1 yr approx 1 bottle daily start from morning. Then patient was taken to deaddiction centre mundian in 2009 and patient had abstinence of alcohol till 2011. Then due to family problems he again started taking alcohol. FAMILY HISTORY:- FAMILY TREE-     FATHER:- Mr. J. A. Rahi, 76 years old, retired employee of CMC blood bank, h/o asthma, hypertension; no h/o of any psychiatric illness; shares good bonding with the patient. MOTHER:- Mother died at the age of 52 years, in 2003, after 2-3 months of elder son’s death; there was no h/o any psychiatric illness. She was close to the patient. Sister:- Rubina; 45 years old, graduate worked as teacher at Wylie school; no h/o any medical or psychiatric illness, good bonding with the patient. Brother:- Bobby Rahi; 34 years at the time…

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Patient Has Been Diagnosed With Perineal Tear, And Vaginal Childbirth. Jc Has A 20 Gauge Peripheral Iv Site In His Left Posterior Forearm

Case study NURS 208 9-28-11 Mrs. Lattamore Dayna Lancaster JC is a 30 year old white female being cared for at Princess Anne Hospital she was admitted on September 20th she presented with abdominal and lower back pain. Mrs. JC has been married for six years prior to current child she has no children of her own. Mrs. JC was originally born and raised in Fallon, Nevada. She is not a smoker and during her pregnancy she had not consumed any alcohol. After discharge JC plans to be a stay at home mother until Breanna is one year of age. Patient has been diagnosed with perineal tear, and vaginal childbirth. JC has a 20 gauge peripheral IV site in his left posterior forearm. Currently JC has a full code and she is allergic to sulfur drugs. She responds to verbally commands well though she does seem to be lethargic due to recent vaginal delivery. She has been placed on a regular diet as of 0400 on 9/20 post delivery. JC does not require assistance with ADL’s. On September 21st 2011 at 0304 JC gave birth to a 4lb 7oz baby girl by the name of Breanna. JC was 38 gestational weeks when she went into labor, she had a vaginal birth. Childbirth also called labor, birth; is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman’s uterus. The process of normal human childbirth is categorized in three stages of labor: the shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta. In many cases, with increasing frequency, childbirth is achieved through caesarean section, the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth. Perineal…

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Past Health History

I. PERSONAL DATA: Name: Mrs. Suarez, Abundia Age: 92 years old Address: San Antonio St. Inupacan Leyte Sex: Female Date of birth: December 23, 1917 Place of birth: Inupacan Leyte Civil status: Widowed Nationality: Filipino Religion: Roman Catholic Ed. Attainment: College Graduate Occupation: House Wife Date of Admission: December 07, 2010 @ 10:30 pm Chief complaint: LBM with intermittent fever and injury on the head Initial diagnosis: – AGE with mild dehydration HPN stage II Final diagnosis: Community Acquired Pneumonia Attending Physician: Dr. Source of info: Amalia I. Suarez (Daughter) Reliability: 70% (seventy percent) According to the daughter of the patient 3 days prior to admission at Bethany Hospital, the patient experienced a passage of loose-watery stools, non-bloody, non-mucoid accompanied with an intermittent fever with mild cough. The manifestations start an hour after the patient ate an uncooked peanut. The patient used to take an oral antipyretic which is Biogesic every 4 hours during the onset of fever for relief and Flagyll, Bactrium and Hyanite for an aid of diarrhea. 1 day prior to admission, while the patient is going to the bathroom, she accidentally slipped and slammed her head, which eventually prompt her daughter to bring her to Hospital hence this admission and had been initially diagnosed with AGE, HPN, and Mild Aortic Stenosis leading to Concentric left ventricular hypertrophy with adequate systolic function and finally diagnosed with Community Acquired Pneumonia. The patient’s daughter claimed that his mother suffered from childhood illnesses such as chicken pox, measles, cough/cold and fever and had taken some herbal medicine as a relief for cough/cold and sometimes Biogesic for fever management. The informant also talked about the admission of the patient to Bethany due to pneumonia, valvular heart disease and undergone surgery due to haemorrhoids. The patient has an allergy to hair colours…

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Nursing Assessment

I. NURSING ASSESSMENT A.Personal Data Patient’s Name: Jahzeel Mary D. De Paz Age: 6 yrs. old Birth date: November 22, 2003 Address: Youngfield, Tacloban City Sex: Female Religion: Baptist Civil Status: Single Father: Darrius De Paz (Bombay collector) Mother: Merrian De Paz (house wife) Diagnosis: Urinary Tract Infection Physician: Dr. Ramas Source of information: Mother Reliability: 95% (reliable) Present Illness: Condition started 3 days prior to interview as an onset of an intermittent Fever, Dysuria and Incontinence, used TSB as a relief for fever. Persistence of above symptoms prompted her family to consult a physician. Past Medical History: Patient was hospitalized at the age of 6 year old, due to Bilateral Hernia surgery last May 7, 2010 at EVRMC. Jahzeel again has been hospitalized last june 2, 2010 at City Hospital due to UTI, associated with fever and cough, and use amoxiclav 7ml 3x a day for 7 days, paracetamol (vial) for relief. The mother also claimed that her daughter experienced Mumps, no treatment used. Never experience measles, chicken pox. Jahzeel is a fully immunized child, as what the mother said. Family History: The mother claimed that they have heridofamilial disease, such as arthritis on the mother side. No known genetic disease on paternal side. Birth History: The client is the 2nd sibling of Mr. and Mrs. De Paz, via normal delivery last November 22, 2003 at EVRMC. Feeding History: The patient was breastfed from birth until 3 yrs old and 6 months. No alternative milk used. They started supplementary feeding at an age of 7 moths, such as cerelac, smashed squash, lugaw etc. take vitamins (tiki-tiki, celine). Growth and Development: Complete tooth but defective, at the age of 4 years old the client began to use toilet with assistance. Her behavior coincides with the normal developmental theories. Psychosocial History:…

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