MEDICAL COLLEGES OF NORTHERN PHILIPPINES

Alimannao Hills, Peñablanca, Cagayan

Telefax No. (078) 304-1010 Website: www.mcnpisap.com
E-mail Address: adminoffice@mcnp.edu.ph

CASE STUDY

Personal Profile:
Name: Maureen Wroble
Age: 28
Sex: Female
Marital Status: Single
Occupation: Online Seller
Address: Tuao, Cagayan
Educational Attainment: College graduate
Nationality: Filipino/German
Religious Affiliation: Roman Catholic
Date of Birth: December 17, 1988
Place of Birth: Penablanca, Cagayan
Date and Time of admission: December 5,
2021
Admitting Physician: Dr. Steffi Aberas

A. Chief Complaint

Patient Maureen Wroble, a 28 year old female, was brought by her sibling for
Consultation at the hospital on December 5, 2021 due to complaint of
body weakness.

B. Admitting Diagnosis

Anemia of Chronic Disease probably secondary to:

1) Blood dyscrasia
2) Chronic Gastrointestinal blood loss

C. History of Present Illness

3 weeks prior to admission, the patient complained of dizziness without
associated easy fatigability, loss of consciousness, and chest pain. She also
noted of epigastric pain with burning sensations that is relieved by food intake.
No weight loss was noted. No consultation was done prior to admission. Few
hours prior to admission, the patient complained of dizziness which is not
tolerable, easy fatigability and pallor. She decided to seek consultation at the
hospital, and was admitted.

LABORATORY RESULTS:
PROCEDURE RESULT REFERENCE

RANGE

December 5, Hemoglobin: 85 Hemoglobin:

2021 M: 136-180 g/L
Complete F: 126-160 g/L
Bloo Hematocrit: 0.25 Hematocrit:
dCount M: 0.04-0.54

F: 0.37-0.47
RBC Count: 2.7
RBC Count:

M: 4.4-6.3 10^12 /L

F: 4.0- 5.1 10 ^9/L

WBC Count: 4.4
WBC Count: 5.0-10.0x/L
Neutrophils: 0.50-
Neutrophils: 0.42
0.70
Lymphocytes: 0.43
Lymphocytes: 0.20-
Monocytes: 0.13
0.40
Eosinophils: 0.02
Monocytes: 0.0-

0.07
Platelet Count: 154
Eosinophils: 0.0-
ABO:B
0.05
Rh: Positive
Basophils: 0.0-0.01
Platelet Count: 150-400x10/
 PROCEDURE DESCRIPTION RESULT

December 5, Imaging method using Impression:

2021 high-frequency sound 1. Mild

Ultrasound waves to diagnose Splenomegaly 2.

whether masses are Sonographically
solid or fluid-filled. normal

liver,gallbladder,

pancreas,kidneys

and urinary

bladder.

COURSE IN THE WARD:

Date/ Time Doctor’s Order

December 5, 2021 ∙ Pls admit to ROC under my service

(+) body weakness ∙ Secure consent for admission and
management
∙ NPO initially
∙ I&O q shift and record
∙ TPR q shift and record
∙ Dx: CBC, Utz
∙ Therapeutics:
- Start PNSS 1L x 8 hours
- FeSO4 + FA 1 tab BID
- Omeprazole 40g/cap OD ac
breakfast
- Start ampicillin-sulbactam 1.5 g IV
q6 hrs x 7 days
- Paracetamol 500 mg tab q4 prn
for fever
∙ Monitor for untoward signs and
symptoms
∙ Refer

December 6, 2021 ∙ Secure consent for blood typing and

cross-matching
Hgb: 85 ∙ Secure consent for BT
∙ Transfuse 2 PRBC 250 ml x 4-6 hrs
∙ Refer

Date: DECEMBER 5, 2021

Time: 10:00 6 PM

Temperature: 37.5 37.8

 Heart 115 100
Rate/Pulse:

Respirations: 22 25

Blood 110/80 110/70

Pressure

O2 Saturation: 85% 88%

Kardex
Mauree
n Femal
NAME: Wroble GENDER e BED #2
CIVIL
STATUS: Single AGE 28 y/o ALLERGIES: None
RELIGION Roman OCCUPATIO Online
: Catholic N Seller BIRTHDAY: December 17, 1998
Tuao,
ADDRESS Cagaya DATE OF December 5,
: n ADMISSION 2021 CLASSIFICATION: PHIC
NURSING LABORATORY/DIAGNOST
ASSESSMENT SPECIAL ENDORSEMENT IC PROCEDURES

10:00 PM

Temperature:
- 37.5
Heart Rate/Pulse:
-80
Respirations:
-18
Blood Pressure
-110/80 Waiting for blood to arrive
Prep for BT
Monitor for untoward signs and symptoms
Physical  Transfuse 2 PRBC 250 ml x 4-6 hrs
Assessment
(+)pallor
CHIEF COMPLAINT

Blood typing and cross-

matching (OR)
body weakness
DIET MEDICATIONS ONGOING IVF
 REMARKS

FeSO4 + FA 1 tab
BID

Bland Diet Started / 6PM

Omeprazole
40g/cap OD ac
breakfast
PHYSICIAN TBA @7AM
- Start ampicillin-
sulbactam 1.5 g IV
q6 hrs x 7 days

Started / 4PM
- Paracetamol 500
mg tab q4 prn for
fever Started / 3:30PM
Dr. Steffi Aberas PNSS 1L X 8hrs
DIAGNOSIS (Remaining : 375ml )
Anemia of Chronic IVF TO FOLLOW
Disease probably
secondary to:
1) Blood dyscrasia
2) Chronic
Gastrointestinal
blood loss PNSS 1L X 8hrs

TPR
PATIENT’S MAUREEN AGE: 28 C.S: SINGLE BED#: 3
NAME: WROBLE

DATE/TIME BLOOD TEMPERATURE PULSE RATE RESPIRATORY

PRESSURE

DECEMBER,
2021

10:00 am 90/70 37.5 115 22

12:00 pm 93/70 37.8 112 25

2: 00 pm 94/70 37.7 100 23

4:00 pm 95/70 37.6 99 22

6: 00 pm 100/80 37.6 89 20

8: 00 pm 105/80 37.5 85 18

10: 00 pm 110/80 37.5 89 18

Doctor’s Order
Patient’s Name: Age: 28 Gender: Cs: Single Bed #: 2
y/o Female
Maureen Wroble

DATE AND TIME PROGRESS NOTES DOCTOR’S ORDER

· Pls admit to ROC under my

12/5/2021 3 weeks PTC, service ∙ Secure consent for
admission and management
10 am (+) Dizziness
· NPO initially
(+) Epigastric pain c · I&O q shift and record
burning sensation · TPR q shift and record
· Dx: CBC, Utz
· Therapeutics:
- Start PNSS 1L x 8 hours
2 hours PTC,
(+) body - FeSO4 + FA 1 tab BID
weakness (+) Dizziness not - Omeprazole 40g/cap OD ac
tolerable breakfast
- Start ampicillin-sulbactam 1.5 g IV
(+) Easy fatigability
q6 hrs x 7 days
(+) pallor - Paracetamol 500 mg tab q4 prn for
fever
(+) consult done - Monitor for untoward signs and
symptoms

BP: 110/80

Temp: 37.5

HR 155

RR: 22

O2 SAT: 85%

Dx:

Anemia of Chronic
Disease probably
secondary to:

1. Blood Dyscrasia
Medication Sheet

DATE OF MEDICAT DOSAGE ROUTE FREQUE DATE OF TIME OF INITIALS

ORDER ION NCY ADMINIS ADMINIS
TRATION TRATION

12/05/21 FeSO4 + PO 1 TAB 12/05/21 6:00 PM G4

FA BID

12/06/21 OMEPRA 40 MG PO 1 cap OD TBA TBA/7:00 G4

ZOLE ac AM
breakfast

12/05/21 AMPICILL 1.5 G IV Every 6 12/05/21 4:00 PM G4

IN - hrs for 7
SULBAC days
TAM

PRN and STAT

DATE OF MEDICAT DOSAGE ROUTE FREQUE DATE OF TIME OF INITIALS

ORDER ION NCY ADMINIS ADMINIS
TRATION TRATION

12/05/21 PARACE 500 MG PO 1 tab 12/05/21 3:00 PM G4

TAMOL every 4
hours as
needed
for fever

I&O
 INTAKE OUTPUT

DATE/SHIF ORA IVF OTHER TOTA URINE EMESI DRAIN OTHE TOTA
T L L S S R L

12-05-21 / 3 750m 625 ml 1.5 ml 1,376. 200 ml 200 ml

to 11 pm l ampicilli 5 ml
n-
sulbacta
m

Individual Output:

https://drive.google.com/drive/folders/19gHR-
WFKiW2Excdc3wx3FYbA6eLRwu6jFlaaKx8TzZei8fscLSzcVEhzadcDlRY7RdUkujbx