Good morning po Dr.

Chua- Chan

Cabellion Sheniel

24/F

Cc: cough

HPI:

2 mos PTA: had cough, whitish sputum, no colds no DOB no fever, decrease oral intake

No consult was done no meds taken

2 weeks PTA: still with cough, whitish to yellowish sputum, now associated with DOB, low grade fever at
nights, chills with weight loss, (+) back pain pricking in char painsclae 4-5/10

No consult done. Self medicated with salbutamol neb as needed which afforded temp relief for DOB

Few hrs- back pain worsen 7-8/10 painscales, still with cough with yellowish sputum

Persistent of symptoms prompted to sought consult

Past medical History:

DM- July 2019 no home medications

Family history:

DM - mother

A: Community acquired pneumonia MR

Diabetes Mellitus type 2, newly diagnosed

T/c pulmonary tuberculosis

PE: awake conversant not in distress

BP: 100/70

CR:93

RR:21
T:36

Anicteric sclera, pink palpebral conjunctiva

No rectraction, (+) crackles, lower Left lung field

(+) decrease breath sound, basal Left

Adynamic precordium, no murmur

Soft nontender

FEP, no edema

P: Dx: CBC

CBG: 327mg/dl- 8hr after last meal

CXR PA

*initial: PTB, right; Pneumonia, Left; minimal effusion, Left

FBS, HBA1C, Crea, ALT,

Tx: at ER, PNSSx 500cc in 1hr

Regular Insulin 10'u' SQ then repeat CBG: 195mg/dl

IVF PNSS× 125cc/hr

-Ceftriaxone 2gm+90ccPNSS OD

-Azithromycin 500mg/cap OD

-Paracetamol 500mg/tab OD

-Insulin 70/30, 16u in am

8 in pm

Monitor VS q 4

Thank you po Doc

Cc: Dr. Mangulabnan/Failon/Butay