Name – Bataluna Lilia Pareja

Age/sex – 86/Female

Dob – 03/30/1937

Place – Mulao Compostela, Cebu

Civil status – window

Nationality – Filipino

Religion – protestant

Date – 7/14/2023

Attending Physician – Dr. Echin

No of admission in mendero – 1

Cc – Hypertension

HPI

5 days PTA, patient noted with increased blood pressure with fatigue.

3days PTA, patient visited MMC for consultation with Dr. Ratunil due to fluctuating BP

Patient visited local hospital for UTI

Hypertension, epigastric pain and dysuria persisted . Hence admitted in the ER

Past Medical History

Patient had a history of diabetes since last year

Patient was hospitalized for hypertension 7 years ago at uv gullas Hospital, Talamban.

Patient had a history of cataract surgery 5years ago

Family History

Mother – (+) hypertensive (decreased)

Father – (+) hypertensive (deceased)

Husband – deceased

Personal and Social History

Non allergic to food and medications.

Non smoker and non alcoholic

OB Gyne History

Apgar score - G2P2

Menopause at the age of 50

Review of system
General – (-) fever, (-) chills, (+) fatigue, (-) weight loss

Heent – (-) contact lens, (+) glasses, (+) blurry (-) visual loss, (+) sore throat, (-) swollen neck.

Skin – (-) colour change, (-) rashes

Respiratory – (-) Sob, (-) wheeze, (-) asthma, (-) cough

CVS – (-) chest pain, (-) murmers

GI – (-) nausea, (-) vomiting, (-) diarrhea

GUT – (+) dysuria, (-) masses, (-) discharge

Musculoskeletal – (-) muscle weakness, (-) Joint pain

Physical Examination

Vitals

HR –

RR -

T–

O2 –

Weight – 85kg

Height – 163cm

General – Awake, alert, Responsive, not in distress

Skin – warm to touch, good skin Turgor

Heent – (+) pigmented sclera, (+) PPC, (-) Sunken eyes, (+) dry lips.

Chest and Lungs – ECE, CBS, Regular Rhythm, normal RR

CVS – DHS, (-) tenderness

Abdomen – soft, (+) tenderness in all quadrant S while palpating

GUT – (+) dysuria, (+) frequency, yellow colour

Extremities – strong pulse, (-) edema

Neurology – unremarkable, GCS score is 15

IMPRESSION – Complicated UTI, HPN

Diagnostic Test

CBC, UA, ECG, Na, K,Cl, Ca, BUN, RAT, CBG

COURSE AT ER

Visited ER at July 14th, 11.45am

5days PTA, history of Hypogastric pain with the pain score of 3, and elevated BP
(+) Dysuria, (+) nausea, (+) fatigue

T – 36.1

BP – 140/90

PR – 85

RR – 20

O2 – 95

Medications Given – Losartan 100mg