I.

Demographic Data
Name: E.A.C
Age: 37 years old
Gender: Female
Citizenship: Filipino
Civil Status: Married
Religion: Catholic
Birthdate: October 2, 1974
Place of Birth: Molino, Cavite
Occupation: Housewife
Address:

II. Clinical Data

Chief Complaint: Restlessness
Source of Information: The source of information was taken in the ward of CMC
(Cavite Medical Center)
Past Medical History: The patient was already taking Atenolol, Vestar,
Omeprazole, Clonidine, Dilantin, Simvastatin, and
Losartan prior to her HPN
History of Present Illness: Few Hours prior to patient admission, her BP was
180/80 and there was (+) chest pain. The patient was
given clonidine and isoket to relieve chest pain. At
around 6:30pm, the BP was in 170/80 and there was mild
chest pain. Few hours prior to patient’s admission there
was still (+) restlessness and was brought to CMC
emergency and was confined.
Initial Diagnosis: HPN Urgency
Diet: Low salt, Low fat, DM diet

III. Laboratory

COMPLETE BLOOD COUNT

(January 16, 2011)

REFERENCE RESULT
Hemoglobin (M) 140 – 180 g/L
(F) 120 – 160 g/L 116g/L
Hematocrit (M) 0.40 -0.54
(F) 0.37 – 0.47 0.352
RBC (M) 4.5 – 5.5 x 10**/L
(F) 4.0 – 5.5 x 10**/L 4.0
WBC 5.0 – 10.0 x 108/L 6.7
Platelet ADEQUATE
Lymphocytes 0.25 - 0.35 0.25 - 0.35.41
Segmenters 0.55 – 0.65 0.55 – 0.65.59
Platelet Ct. 150 – 450x109/L 208 x 109/L
 SERUM TEST
(May 10, 2010)

REFERENCE RESULT
Na 137 – 145 121.0 mmol/L
k 3.5 – 5.1 3.7 mmol/L
Cl 98 – 106 mmol/L 88mmol/L

IV. Physical Assessment

General Survey: Conscious, coherent

Weight: (x)

V. Gordon Functional Assessment

VI.

Risk Factors
Family Hx Obesity
Age Alcohol Consumption
High Na intake Smoking
Low K inatake Stress

Changes in arteriolar bed

Systemic Vascular Resistance

afterload

Blood Flow to organs

 Risk Factors
Family Hx Obesity
Age Alcohol Consumption
High Na intake Smoking
Low K inatake Stress

Changes in arteriolar bed

Systemic Vascular Resistance

afterload

Blood Flow to organs

Renal perfusion Beta receptor

Blood pressure activatioon

hyponatremia Juxtaglomerular cells hypovolemia

angiotensinogen
renin Angiotensin I

Angiotensin – Converting Enzyme (ACE )

Arteriolar vasoconstriction Angiotensin II

Peripheral resistance Adrenal cortex

Stimulation II

aldosterone

Blood pressure Na reabsorption

H2O reabsorption

Plasma volcano (ECF)