PATIENT INFORMATION

ADMISISON AND DISCHARGE RECORD

Name of Patient: Castillo, Jane
Religion: Roman Catholic
Age: 45
Address: Recodo, Zamboanga City
Admission Date/Time: June 19, 2021, 3:35 PM
Ward/ Room: Ward C/ Room 310
Attending Physician: Dr. Danny Yap
Admitting Diagnosis: Hypovolemic Shock Secondary to Upper Gastrointestinal Bleeding
Secondary to Bleeding Peptic Ulcer Disease
Final Diagnosis: Not specified yet

History of Present Illness:

Hours prior admission, out of hematemesis amounting to 500mL, patient experienced difficulty of
breathing. Persistence of such symptom prompted patient to seek consult at the nearest hospital
and was managed subsequently. Patient then was referred to this facility per request.

Past Medical History:

(+) Hypertension
(+) Chronic Alcoholic Liver Disease
(+) Bleeding Peptic Ulcer Disease

Physical Examination on Admission:

General Survey: Awake and alert
Vital Signs: BP 90/60mmHg HR 98BPM RR 24BPM T 36.7OC O2 sat 95%
EENT: Icteric Sclerae
Chest and Lungs: Essentially Normal
Cardiovascular : Essentially Normal
Abdomen: Essentially Normal
Genitourinary: Essentially Normal
Skin: Essentially Normal
Neuro: Essentially Normal
Need for Isolation: Standard Precaution

Admitting Orders:

Please admit to room of choice under the service of Dr. Danny Yap
• Secure consent
• Vital Signs Q4
• IVF PNSS 1L at 20gtts/min
• Diagnostics:
o CT Scan of the Abdomen With Contrast
o ECG 12L with LL II
o CXR
 o CBC, Na, K, Creatinine, BUN, BUA, SGPT, SGOT, HBA1C
o FBS and Lipid Profile
o Urinalysis
• Continue maintenance medications:
o Amlodipine (Amlocare) 10mg/tab 1 tab OD
o Metformin (Imax) 500mg/tab 1 tab OD
o Clopidogrel (Plavix) 75ng/tab 1 tab OD
• Vitamin K 1amp IV Q12
• Furosemide 20mg/amp 20mg IV OD
• I and O Q shift
• Refer accordingly

Additional Orders:
• Omperazole 40mg IV Q12
• Maintain on NPO
• Watch out for loss of consciousness, seizure, desaturation, decrease in sensorium and
chest pain

ASSESSMENT TASKS!
1. Demonstrate how the student nurse proceeds in meeting the patient.
2. Take the vital signs and record them on the monitoring form.
3. Conduct a comprehensive nursing health history and physical assessment.
4. Identify drugs ordered and taken by the patient.
5. Determine three actual or potential problems based from the data gathered.

WRITTEN OUTPUT
1. Nursing Health History
2. Drug Study for Vitamin K and Furosemide (Prepare for Oral DS for all meds)
3. Formulate ONE nursing care plan based from the problems identified