Date of Assessment: February 15, 2020

Patient History & General Information

Name of Patient: Evelyn Borromeo Age: 52 Gender: Female
Marital Status: Married
Religion: Roman Catholic Date/Time Admitted: Feb.14,2020/1150H
Information Provided by: Medical Chart

History of the Present Illness

Chief Complaint: Difficulty of Breathing

Summarized Current Illness Episode:

Patient is diagnosed with asthma since she was just a child. She grew up
having bronchodilators as her reliever with nebulizer and inhaler as the device.
One day prior to patient’s admission she went to Mary Mediatrix Medical Center
together with her cousin complaining of difficulty of breathing.

Patient shared that the climate change here in the Philippines triggered her
asthma sudden change from cold weather to hot weather, causing her difficulty of
breathing.

Adm Dx: Bronchial Asthma in Acute Exacerbation

Vital Signs: Temp: 36.8°C PR: 102 bpm RR: 21 bpm BP: 110/70 mmHg
Height: 5’2” Weight: 62 kg

Past Medical History

Family History
(+) Hypertension
Past Medical & Surgical History
No past medical history. No surgeries was done to the patient.

Food/Drug Allergies
The patient has no known allergies.

GENERIC NAME BRAND NAME MAJOR DRUG

CATEGORY
Montelukast +
Levocetirizine Zykast Antihistamine
DRUG ACTION USES SIDE EFFECTS/ADVERSE
REACTIONS
Montelukast inhibits
broncho constriction due Used to relieve  Stomach Pain
to antigen challenge. symptoms of  Rash
Montelukast is a selective allergic rhinitis  Dizziness
leukotriene receptor (seasonal and  Nausea
antagonist of the perennial)
cysteinyl leukotriene
receptor.
SIGNIFICANT DRUG USUAL DRUG CONTRAINDICATIONS
INTERACTION DOSE
10mg 1 tablet, per  Hypersensitivity
None orem, once a day

NURSING MEDICATION MANAGEMENT

ASSESSMENT INTERVENTION
 Monitor respiratory status  Unusual change in respiratory
 Assess for adverse effects status should be immediately
reported
EDUCATION EVALUATION

 May be taken with meals  Monitor respiratory status prior to

 Report for any adverse reactions and periodically throughout therapy

GENERIC NAME BRAND NAME MAJOR DRUG

CATEGORY
Acetaminophen Paracetamol Analgesic

DRUG ACTION USES SIDE EFFECTS/ADVERSE

REACTIONS
Pain relief may result
from inhibition of Relief of mild to  Rash
prostaglandin synthesis moderate pain;  Sore throat
in CNS, with subsequent treatment of fever  Dizziness
blockage of pain  Nausea
impulses.
SIGNIFICANT DRUG USUAL DRUG DOSE CONTRAINDICATIONS
INTERACTION
None 500 mg Per orem, as  Hypersensitivity
needed

NURSING MEDICATION MANAGEMENT

ASSESSMENT INTERVENTION
 
 Assess patient’s fever or pain; type  Notify physician if pain/fever lasts
of pain, location, intensity, and for more than 3 days
duration
 Assess allergic reactions

EDUCATION EVALUATION

 Taken with meals  Monitor temperature for fever or

 Report for any adverse reactions pain

Date of Assessment: February 15, 2020

Patient History & General Information

Name of Patient: Hitachi L. Kuruko Age: 25 Gender: Female

Marital Status: Married
Religion: Roman Catholic Date/Time Admitted: February 13, 2020 1200H
Information Provided by: Medical Chart/Interview

History of the Present Illness

Chief Complaint: Severe pain on the right lower quadrant of the
abdomen
Summarized Current Illness Episode:

The patient was experiencing diarrhea (7x) and vomiting (3x)

three days prior to admission. His last meal was beer, chicharon and
isaw. The had taken diatabs but still had diarrhea then accompanied by
fever 1 day prior to admission.
Adm Dx: Acute Gastroenteritis with Moderate Dehydration

Vital Signs: Temp: 36°C PR: 82 bpm RR: 20 bpm BP: 110/70
mmHg Height: 175cm” Weight: 83 kg

Past Medical History

Family History
(+) Diabetes Mellitus on the father’s side
Past Medical & Surgical History
Patient has never been hospitalized and no known history of surgery.

Food/Drug Allergies
The patient has no known allergies.

GENERIC NAME BRAND NAME MAJOR DRUG

CATEGORY

Bacillus Clausii
Erceflora Anti-diarrheals

DRUG ACTION USES SIDE

EFFECTS/ADVERSE
REACTIONS
Contributes to the
restoration of intestinal
Acute diarrhea  Rash
bacterial flora that has
been upset by  Urticaria

imbalances of various  Angioedema

origins.
SIGNIFICANT DRUG USUAL DRUG CONTRAINDICATIONS
INTERACTION DOSE
none 1 vial per orem 2x a  Hypersensitivity
day

NURSING MEDICATION MANAGEMENT

ASSESSMENT INTERVENTION

 Monitor I and O  Monitor I and O

 Monitor bowel sound  Monitor for electrolyte
imbalance
EDUCATION EVALUATION
1. May be taken with or Relieve hyperactive bowel sound.
without food
2. May dilute contents of vial in
milk, water or juice.