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Name: Michelle Tandora FernandezAddress: Prk. 10 Emerald St. Doa
Salud Subd., Sasa, Davao CityBirthday: January 13, 1985
Age: 28 years oldSex: FemaleOccupation: Call Center
representativeRm-Bed: 3017-1/ Semi-privateReligion: CatholicCivil
Status: Married
Admission date: 03/03/2013Admission time: 07:52 AMAdmitting
physician: Yasmin Grace Yap Lao, M.D
Admission Diagnosis: Acute Gastroenteritis with moderate
dehydrationFinal Diagnosis: Acute Gastroenteritis with moderate
dehydration
Surgical procedure: NONE
Drugs3/13/2013
Metoclopramide (Plasil) 1 amp IVTT q 8 hours as needed for
vomitingHNBB 1 amp IVTT q 8 hours as needed for crampy abdominal
pain
3/04/2013
Ciprofloxacin (ciprobay) 500 mg 1 tab
STAT3/13/2013
Omeprazole 40 mg IVTT nowCloprimed 1 amp IVTT nowBuscopan 1 amp
IVTT now
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28 G1P1 (1001)
CC: Vomiting, LBM
PMH: non-hypertensive, non-diabeticS/P: CS x 1 for fetal
distress(+) allergy to ibuprofen, celecoxib, mefenamic acid,
ketorolac, meloxicamNo food allergy
PSHx: non-smoker, non-alcoholic beverage drinker
HPI: patient was apparently well until few hours PTA when she
noted suddenonset of
Crampy abdominal pain, 8/10 in severity, associated with LBM of
non-smelling
stools x 4 episodes and vomiting x 4 episodes. Persistence
prompted thisadmission.
PE: examined pt. conscious, coherent, in acute painVS within
normal
AS, PPC, dry lips and tongueClear breath soundsNormal cardiac
rate and rhythmFlabby abdomen, hyperactive BS, soft and no
tendernessFull pulses
Impression: same as diagnosis
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UrinalysisEXAMINATION / RESULT / UNIT / RANGE / RESULT /
REMARKS
U/A color YELLOWU/A character CLOUDU/A reaction 5.5U/A spec.
gravity 1.030U/A albumin TRACEU/A sugar (-)U/A othersWBCUL 11 /ul
0-17WBCHPF 2 /hpf 0-3RBC UL 3 /ul 0-11
RBC HPF 1 /hpf 0-2ECUL 20 /ul 0-17 HECHPF 4 /hpf 0-3 HCASTUL 0
/ul 0-1BACTUL 121 /ul 0-278BACTHPF 22 /hpf 0-50U/A remarksU/A pus
cell /hpfU/A RBC /hpf U/A CAST /lpfU/A CRYSTALU/A MUCUS THREADU/A
SQUAMOUS
U/A RENALBACTERIA
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Legend : THE SAME (=)
CBC
Hgb 135 g/l 120-140Hct .42 .37-.45Wbc 22.80 10s9/l 5-10 HSeg.
.880 .55-.65 HLymphocytes .060 .35-.45 LMonocytes .050 .06-.12
LEOSINOPHIL .010 .02-.04 LBASOPHIL .000 0-0.020
ABSOLUTENEUTROPHIL 20.29 10s9/l 1.8-7.8 H
ABSOLUTE LYMPHOCYTE .87 = 1.0-4.8 L= MONOCYTE 1.2 = 0-.80 H=
EOSINOHIL .25 = 0-.45
ABSOLUTE BASOPHIL .21 = 0-.020 HRBC 4.62 10s12/L 4.5-5.0MCV 92
fl 80-97MCH 29.20 pg 27-31.2MCHC 316 318-354RDW 11.70 11.5-14.5MPV
7.30 fl 2-20PH count 413.00 10s9/l 1470-440
STOOL 1 Light brown,waterySTOOL 2 (=)STOOL 3- brown, watery
No ova/ parasite seen
