PCI: PATRIARCA, JANNA MAE H.

STATION: MEDICAL WARD

ADMITTING DIAGNOSIS: ACUTE GASTRITIS

A. Profile of Patient

Patient’s Name : Ms. lee

Address : Banlag, Valencia city bukidnon
Age : 35 y.o weight: 52kg
Sex : female height: 165cm
Birth Date : 01-14-1986
Religion : Roman Catholic
Nationality : Filipino
Civil Status : single
Occupation : call center agent
Date of Admission : 05-19-2021 7:34 am
Admitting Diagnosis : acute Gastritis
Attending Physician : Dr. Mateo
Chief complaint: abdominal pain with pain scale of 10/10

Case scenario
On may -19 -2021, 7:34 am patient is a 35 years old woman who was brought
to the emergency department by her aunt. Patient complains of abdominal pain with
a pain scale of 10/10.she Appeared Irritable, restless, weak, facial grimace, sunken
eyeballs and crying. Her vital signs are temperature: 37 .5, pulse rate: 84bpm
respiratory rate: 20cpm, blood pressure: 140/80 mmhg, and Spo2: 93%. Upon
admission patient experienced diarrhea and vomiting with blood. Patient stated that
she has been taking ibuprofen 400mg 4x a day when she had headache since 3
weeks. Dr. Mateo has been ordered medications for diarrhea, vomiting and pain and
request for laboratory test: CBC, U/A/ H-PYLORI TEST, Pregnancy test, Na and, K.
On may-20-2021, Nurse on duty noticed that the Patient skin appeared pale,
cold and clammy. Facial grimace, guarding behaviour, weak, irritable and restless
still noted. Patient still complains of abdominal pain in the mid-upper stomach region
with a pain scale of 8/10, moderate diarrhea, vomiting and loss of appetite. V/S
monitored as follows are temperature: 36.8, pulse rate: 88bpm respiratory rate:
21cpm, blood pressure: 140/80 mmhg, and Spo2: 94%. Tramadol was given by the
nurse ,seen and was Examined by Dr. Mateo. Abdominal pain was due to gastritis
with final diagnosis of acute gastritis. Lab Results showed high WBC Low RBC, Low
platelet, low hematocrit,
On the third day of admission, the patient was still noted weak and restless
but increased of appetite reported. Still complains of pain in mid-upper stomach
region with a pain scale of 4/10.diarrhea and vomiting stop. Diet as tolerated. Monitor
vital signs temperature: 36.5, pulse rate: 87bpm respiratory rate: 20cpm, blood
pressure: 110/80 mmhg, and Spo2: 94%. Seen and re-examined by Dr. Mateo with
orders.

B. Doctor’s Order

Date Order

05/ 19/2021
 Pls. Admit to the medical ward
7:34am
 Secure consent to care and mgt
 Diet : DAT
 IVF: PNSS 1L @ 25gtts Fast drip 200cc
 Monitor V/S q4, O2 sat q4
 Labs: CBC, U/A, H-Pylori test, Pregnancy test, Na, K
 , Meds:
-metoclopramide 10mg IV now then q8 prn
-omeprazole 40mg Cap BID
-mucusta 100m tab TID
 I and O q shift
 Refer for persistent vomiting, severe abdominal pain or any
unusualties
 Refer accordingly
Dr. Mateo

05/20/2021  Give Tramadol 50mg IV now

10AM  For UTZ of upper abdomen
 For CT scan
 DAT
 Tramadol 50mg q8h
 IVF TF: PNSS IL @25gtts/min x 3 bottles at same rate
 Cefuroxime ( Kefox ) 750mg IVTT ANST then q8h
  Monitor signs of abdominal pain or any unusualties
 Refer accordingly
Dr. mateo

05/20/2021  Continue present intervention

9:30AM  IVF TF: pnss IL @ 25gtts/min
 Continue monitor signs of abdominal pain
 I and O q shift
 Refer accordingly
Dr. Mateo

HEMATOLOGY (05-20-21)

Test Result
Total WBC 14,000mm3
Total RBC 5.25 million/mm3
Hemoglobin 9.0 g/dL
Hematocrit 50
MCV 100fl
MCH 33.49
MCHC 32.0 g/dL
Platelet Count 81,000 per ul
Differential Count
Neutrophils 77.50 %
Lymphocytes 19.20 %
Monocytes 7.10 %
Eosinophils 16%
Basophils 0.10 %
RDW - CV 11.6 %
BLOOD CHEMISTRY
sodium 143.3
potassium 3.32
SEROLOGY
H.PYLORI (+)
 URINALYSIS
(05-20-2021)

Test Result
Macroscopic
Color Yellow
Appearance Clear
Glucose Negative
Protein Negative
Reaction 6.0 pH
Specific Gravity 1.020
Microscopic
Epithelial Cells Few
Mucous Threads Rare
Urates None Seen
Bacteria Few
Pregnancy test (-)

Ultrasound report (MAY-21-2021)

Ultrasound of the Upper Abdomen

MEASUREMENTS
R Liver Lobe =14.73cm R Kidney =10.51 x 4.12 x 4.19 cm C-T = 0.97cm
L Liver Lobe= 12.82cm L Kidney=11.7 x 5.13 x 5.44 cm C-T =1.39cm
Gallbladder= 6.25 x 2.26 x 1.69cm Spleen = 9.40cm
Impression: NEGATIVE ULTRASOUND OF THE LIVER , INTRAHEPATIC DUCTS,
EXTRAHEPATIC DUCTS, GALLBLADDER, PANCREAS, SPLEEN AND BOTH KIDNEYS.

Abdominal radiography reveals thick folds, inflammatory nodules, coarse

areas of the gastric mucosa and erosions.
Computed tomography scanning reveals thickening of the gastric wall.
20 p0int quiz

1. What are the sign and symptoms of acute gastritis? (2 POINTS)

2. What is the cause of acute gastritis? (2 points)
3. How do you assess a patient with acute gastritis? (5 point)
4. What are your health teachings to prevent acute gastritis? (5points)
5. The nurse is reviewing the medication record of Ms. Lee with acute
gastritis. Which medication is not considered?
a. Metoclopramide
b. Omeprazole
c. Tramadol
d. Mefenamic acid

6. Patient lee is diagnosed with acute gastritis secondary to alcoholism

and cirrhosis. when obtaining the clients history, the nurse gives
priority to the clients statement:
a. His pain increased after meals
b. He experience nausea frequently
c. His stools have a black appearance
d. He recently joined alcoholics anonymous

7. Which test is not used to detect H pylori

a. Serologic tests
b. Rapid urease
c. Urine test
d. Fecal antigen antigen test
e. Urea breath test
8. Physician orders 1000ml of PNSS to infuse over 12 hours, how many ml
would infuse per hour? 83ml/hour
9. The doctor orders 1liter of normal saline for 8 hours. The drop factor is
20gtts/ml. What is the flow rate? 42gtt/min
10. Which of the following substances is most likely cause of acute
gastritis?
a. Milk
b. Bicarbonate of soda, or baking soda
c. Enteric coated aspirin
d. Nonsteroidal anti-inflammatory drugs