St. Scholastica’s College Tacloban, Inc.

Campetic Maharlika Highway Palo, Leyte

DEPARTMENT OF NURSING

DUTY REQUIREMENTS:
MEDICAL-SURGICAL WARD (4A)
CLINICAL GROUP 1B

Submitted by:
BELLEZA, LUCIL JAINE A. BSN 4-A

Submitted to:
Mrs. Rizza M. Estil, RN, MAN

January 20, 2022

 PATIENT’S INFORMATION

Patient’s Initials: R., M G.

Birthplace: Abuyog, Leyte
Age/Sex: 58 years old/ MALE
Date of Birth: 02/01/1964
Nationality: Filipino
Civil Status: Married
Address: Brgy. Libertad Abuyog, Leyte
Religion: Assembly of God
Contact No.: 09351281156
Father’s Name: Panfilo Rufin
Mother’s Name: Maria Gula
Occupation: Pastor
Employer: Assembly of God
Employer’s Address: Brgy. Libertad Abuyog, Leyte
Case No.: 23010362
Med. Case No.: 240279
Patient No.: 00168545
Room No.: 419
Attending Physician: Palermo, Marjorie A.
Hospitalization Plan: Informal Economy
Type of Service: Medical Surgical
Admitting Diagnosis: Myocardial Infarction; Type II Diabetes Mellitus, Insulin Requiring,
Hypertension Stage II
 Patient’s History

Chief Complaint/s

Chest pain, dyspnea

History of Present Illness

4 hours prior to admission, the patient had sudden onset of chest pain, PRS of 6/10 deciphered as
chest heaviness, non radiating. It was associated with dyspnea, however eventually resolved. No medication
was sustained. Patient immediately seek consult to our center for admission.

According to the patient, around 6:00pm he was resting and he stated that his blood sugar was
already high upon checking. 7:00pm, he was getting ready to sleep when he felt his a tight, abrupt pain on
his chest, his body was chilling, and he had cold sweats. He asked his wife to help him sit, meanwhile, his
children tried to alleviate his pain by massaging the area. He tried really hard to catch his breath,
approximately 5 minutes, his family called for transportation, and they travelled immediately to DWH
wherein they were assessed by the ER staff. Patient was admitted last January 15, 2023. BP was 90/50. 4
years ago, he was previously admitted at DWH and was diagnosed with Type 2 Diabetes Mellitus, his CBG
was 500mg/dL. He is taking insulin and metformin for his diabetes. He also reported he was having joint
pain, he tells us that he thinks his rheuma was triggered again after he ate yellowfin fish for lunch.

Past Medical History

Type 2 Diabetes Mellitus, diagnosed 4 years ago under the service of Dr. Palermo. Rheuma,
diagnosed 3 years ago.

Medications

Pain reliever for his rheuma. Insulin and metformin for his T2DM.

Family History

Mother- deceased- Heart disease

Father- deceased- No known chronic health issues
Brother 1- living- No known chronic health issues
Brother 2- living- No known chronic health issues
Sister- living- No known chronic health issues
Brother 3- living- No known chronic health issues
Children- living- No known chronic health issues

Socioeconomic History

Patient is a highschool graduate, working as a Pastor in his community, living with his wife with his
kids. In his home, the patient feels secure and well-cared for. He works as a pastor, a position that demands
him to be physically fit on a daily basis. His lightheadedness, muscle soreness, and weakness have all had an
impact on this area of his profession. Because of his sickness, the patient is apprehensive about missing
more work. The patient denies ever smoking. Patient previously reported drinking wine socially 1-2 beers,
1-2 times a month, but has stopped drinking since the onset of symptoms 4 months ago. The patient denies
using any recreational drugs. Patient denies any exercise, despite the fact that he feels physically exhausted
every day at work. The patient reports a well-balanced non-vegetarian diet consisting primarily of
home-cooked meat and poultry meals.

Review of Systems

General Appearance: no body malaise

Skin: Good skin turgor, no skin lacerations
HEENT: no hemophysis
Respiratory: (+) dyspnea, no cough, no colds
Cardiac: (+) chest pain, no palpitation
GIT: no abdominal pain, no diarrhea, no constipation, no melena
GUT: no dysuria, no urinary frequency
 Doctor’s Orders

01/15/2023 3:50pm
CC: chest heaviness
T: 36
BP: 90/50
PR: 110
RR: 24
BL: 5” 4’
WT: 112 kg
O2 SAT: 98%
- Please admit patient to the room of device under the service of Dr. Palermo.
- Secure consent for admission and management.
- TPR q shift.
- Start diabetic diet at 1800 kcal/day with the following distribution. Give in 3 equally feedings with
snacks in between.
CHO: 270gm/day
CHON: 68gm/day
Fats: 115gm/day
- IVF: PLR 1L at 30cc then regulate at 20 gtts/min.

Diagnostics:
CBC, platelet
Na, K, Cl, creatinine
BUN, BUD, SGPT
R-L ECG
Chest XRAY PA View
FBS, lipid profile
FT3, FT4, TSH
Urinalysis
Troponin I stat
RT PCR covid 19
CBG

Therapeutics:
Atorvastatin 40mg 1 tab OD at HS
Carvedilol 6.25mg 1 tab OD PO at PM (PS)
Insulin glargine 48 units SC OD at 5PM (PS)
Linagliptin+metformin 2.5mg/500mg (trajenta) 1 tab BID PO pc meals (PS)
Vitamin B complex 1 tab OD PO (PS)
I&O every shift
V/S q 4h

- refer to Dr. Michael for pt cardio evaluation and consultation.

- CBG premeals TID and 2h post dinner
- Pantoprazole 40mg IV OD

01/16/2023 10:43am
 - Increase insulin glargine to 52 units SC OD.
- Decrease CBG monitoring to BID premeals and 2 hours post dinner.

01/16/2023 2:00pm
- Continue to titrate NE drip.
- Start trimitazidine 35mg 1 tab BID.
- Discontinue other medications.

01/16/2023 11:55pm
- Follow up norepinephrine, downtitrate by 2 cc/m until consumed.

01/17/2023 1:27pm
- IVF to consume then shift to heplock.
- Decrease CBG monitoring to BID premeals.
- Start tansulin 40mg 1 tab OD at HS.
- Start potassium citrate 10mg 1 tab TID after meals.
- For repeat CBC, Na, K, creatinine, and urinalysis tomorrow AM.

01/17/2023 3:40pm
- May discontinue norepinephrine drip.

01/18/2023 9:13am
- Start empoliglatizine 10mg 1 tab now then OD (breakfast.
- Continue other medications.
- Follow up urine CS result.

01/18/2023 9:30am
- Continue meds and start bisoprolol 2.5mg 1 tab OD with BP precautions.
 Summary of Medications

Cefuroxime 170mg IVTT q8h

Cetirizine 5mg/5ml OD h.s
Clarithromycin 250mg/5ml BID PO
Hydrocortisone 50mg IVTT q6h
Montelukast 4mg OD h.s direct to mouth