College of Health Sciences Education

3rd Floor, DPT Building

Matina Campus, Davao City
Telefax: (082) Phone No.: (082)300-5456/300-0647 Local 117

NCM 112/L RLE

Patient Presentation: Angel Locsin, a 28-year-old female, from Juna Subdivision, Panacan Davao City
presents to the clinic with a 10-day history of flu-like symptoms, including anorexia and malaise. She does
not report any pertinent prior medical history or surgeries. She takes no medications. Her family history is
noncontributory, and she reports no sick contacts. She is sexually active with multiple partners and has
used oral contraceptives regularly for the past 12 years. She has not traveled outside the United States in
the past 5 years.
On physical examination, she is alert and oriented, in no acute distress. Her vital signs are temperature of
38 °C, pulse 80/minute, respirations of 20/minute, and blood pressure of 121/78 mm Hg, O2 Saturation:
96%. Her extraocular muscles are intact; however, mild scleral icterus is noted. Heart sounds are regular
rate and rhythm without murmurs, and lungs are clear to auscultation bilaterally. The abdomen is soft and
nontender, except the liver is tender when palpated and extends 8 cm below the costal margin, with a
smooth edge with pain scale of 8 out 10 when palpated.

Date and time of admission: September 13, 2022, 8am

Room and bed #: Room 300-2
Admitting Diagnoses: Influenza; to consider Acute Viral Hepatitis B

Vital Signs 12 noon: Temperature: 36.2 °C, pulse rate 76/minute, respirations 17/minute, blood pressure
115/72 mmHg, O2 saturation 96%

Laboratory Findings:

Complete Blood Count

 College of Health Sciences Education
3rd Floor, DPT Building
Matina Campus, Davao City
Telefax: (082) Phone No.: (082)300-5456/300-0647 Local 117

Basic Metabolic Panel

Liver Function Test

Result Reference Range
ALANINE AMINOTRANSFERASE (ALT) 3817 U/L 7-55 U/L
ASPARTATE AMINOTRANSFERASE (AST) 2152 U/L 8-48 U/L
ALKALINE PHOSPHATASE (ALP) 176 U/L 45-115 U/L
ALBUMIN 3.4 g/dL 3.5-5 g/dL
TOTAL PROTEIN 6.7 g/dL 6.3-7.9 g/dL
TOTAL BILIRUBIN 8.5 mg/dL 0.1-1.2 g/dL

Viral Serology for Hepatitis B

Result Abbreviations: HBc, hepatitis B core; HBeAg, hepatitis B envelope antigen; HBsAg, hepatitis B
surface antigen; HBV, hepatitis B virus; Ig, immunoglobulin.
HBSAG POSITIVE
HBEAG POSITIVE
IGM ANTI-HBC POSITIVE Chest X Ray (PA)
IGG ANTI-HBE NEGATIVE
IGG ANTI-HBS NEGATIVE
HBV-DNA POSITIVE RESULT:

The lungs are clear. Tracheal air column is at midline. The heart
is not enlarged. Hilar structures are unremarkable. Both
hemidiaphragms and costophrenic sulci are intact. No other
significant findings.

IMPRESSION: NORMAL CHEST FINDINGS

RT PCR Test:
 College of Health Sciences Education
3rd Floor, DPT Building
Matina Campus, Davao City
Telefax: (082) Phone No.: (082)300-5456/300-0647 Local 117

Doctors’ Orders:

Day 1 (8am)
 Please admit under my care
 Secure consent
 DAT
 Observe proper precautions
 IV: PNSS 1L @ 120cc/hr x 4 cycles
 Labs:
- Complete Blood Count
- Basic Metabolic Panel
- Chest X Ray (PA View)
- RT PCR for COVID 19
 Medications:
 PPA + ChM tab now then q8 x 3 doses then prn for nasal congestion
 paracetamol 500mg tab q4 PRN for temp. <37.8°C
 metoclopramide 10mg IV now then q8h PRN for persistent vomiting
 Keep well thermoregulated
 Increase OFI
 VS q4h
 I & O q4h
 Refer accordingly

Jean Salagubang , MD
Lic. No. 06533441

Day 1 (2pm)
 Continue Medications
 IV TF: SS @ SR x 3 cycles
 College of Health Sciences Education
3rd Floor, DPT Building
Matina Campus, Davao City
Telefax: (082) Phone No.: (082)300-5456/300-0647 Local 117

 Labs: for Viral Serology for Hep B – PLEASE FACILITATE

 Standby adefovir dipivoxil and lamivudine – check with pharmacy for the availability.
 Give ranitidine 50mg IV now then q8h x 2 doses
 Observe proper precautions
 Facilitate small, frequent feedings
 Advise bed rest.
 Refer accordingly

Jean Salagubang, MD
Lic. No. 06533441

Intake:
9am: 150 cc water
10 am: 100 cc orange juice
11:30: Fried Bangus with 1 cup rice, 1 piece banana
1:00pm: 100 cc water
2:00pm: 200 cc water

Output:
8:30 am: 100 cc urine
11:00 am: 150 cc urine
1:00 pm: defecated once

General Instructions: Transfer all the datas presented in the forms provided.

 Kardex
 VS signs Monitoring Sheet and graphing sheet
 Medication sheet
 Intake and output sheet
 Nurses notes: make 1 FDAR basing on the presenting symtoms