DAR

9/22/10

4pm

D: admitted 75 y.o male with a chief complaint of weakness on both lower

extremities. Observed to have chills, opted to turn off aircon

A: initial VS taken and recorded as follows T= 37.2, RR=21, PR=94, BP= 140/90.
Oriented to hospital rules and policies. Provided with additional layers of blankets.
Facilitated requests for blood extraction at 6pm such as CBC, SGPT, BUN, &
creatinine. Blood extractions for FBS, cholesterol and triglycerides to be done
tomorrow. Instructed family members to inform staff of patient’s last meal today.

R: no more chills observed, relatives verbalized understanding of health teachings.

*1st rounds done. Febrile @ 38.3. instructed by NPO from 8pm-8am for blood
extraction.

D: awake, lying on bed with serum osmolality, urine NA, urine osmolality, PPt, serum
Na 6 hours after hooking 3% NaCl. WOF seizures

A: vs taken and recorded, afrebrile, advise pt regarding lab test. Advise pt NPO.

9/23/10

6am-2pm

8am

D: seen conscious and coherent for blood extraction and urine specimen collection
for 2D echo and Doppler.

A: instructed to be on NPO-TFO, instructed patient’s relative on the proper collection

of urine specimen brought to 2D echo, VS taken, kept comfortable and safe, linens
changed.

R: VS stable, amenable to health teachings.

*facilitated ancillary procedures. Noted revised diet. IVF shifted to PNSS @ 30cc/
hour with repeat Na extraction 6 hours after hooking to PNSS 1L. endorsed for
sputum AFB in 3 consecutive days.
 2-10pm

D: awake on moderate back rest; with ongoing IVF PNSS 1L @ 30cc/hour. Stable VS
for repeat Na 6 hours post hooking of PNSS. No complaints of pain no pending
diagnostics.

A: monitored accordingly. Safety and comfort measure rendered; IVF regulated at

desired rate; assessment for pain on joints, needs attended.

R: stable VS. no pain on joints and bony prominences.

10-6pm

D: labs noted dated 9/23/10 Na=122.5. Pain scale=0.

A: ensure proper regulation of IVF to promote hydration. WOF seizures or any

untoward manifestations. Ensure side rails up at all times to promote safety. Kept
comfortable.

R: stable, safe

9/24/10

6am-2pm

10am

D: seen awake, sitting on bed, afebrile, not in distress. IVF #4, 0.9 NaCl infusing @
30 gtts/min. (- ) pain

A: VS taken and recorded.

R: kept comfortable, needs attended.

D: Na=122. Not in distress or pain. No DOB, adequate urine output. Availing results
of latent blood extraction

A: Vs taken and recorded- due meds given. IVF regulated at desired rate. IVF
infusing well.
HISTORY

CC: generalized body weakness

3weeks PTA the patient was noted to have generalized body weakness. They consulted and
was requested blood tests which showed increased creatinine, increased BUN and uric acid.
Patient’s weakness was accompanied pain on the knee, ankle, and the toe on the right foot.
Patient didn’t complain not until the pain was already graded 10/10. Then was scheduled to
have a consultation here in Manila. But due to his progressive weakness they have been
postponed. Few days PTA the pt felt better hence consult.

PAST HX:

(+) HPN

(-)DM

(-)ASTHMA

FAMILY HX:

(+) HPN

(+)DM

(-)ASTHMA

ADMITTING DIAGNOSIS: t/c GOUTY ARTHRITIS.