JT (jejunostomy tube), IVF (left hand)
07/06 VS: 8am: 140/80, 85, 15, 37C
12n: 140/80, 86, 18, 37C
I&O: NPO/800cc urine q1
NGT: 15cc (8am)
JP: 15cc (8am) q4
IVF: #5 D5NR (3:30am-11.30am) 30gtts/min with 150cc infused at 10-6 shift
> interview: (-) allergies; (+) DM; (+) hpn
> LMBR, EDB, elastic stockings on both legs
> CBG monitoring q8; salbutamol nebulization (alternating with NSS) q4; incentive spirometry q6
MEDS:
07/03 ranitidine 50mg/IV q8
ampi-sulbactin **sulbactan nakita ko sa drug guide** 750 mg/IV q8
07/04 paracetamol 30mg/IV q4
07/05 bactidol gargle for 30 secs for 2 days
07/06 morphine SO4 **morphine sulfate** 0.02%/10cc/EC -- given
! insulin given on 07/04 @ 8pm = 156 mg/dL
07/05 4am = 136 mg/dL
12N = 120 mg/dL
8pm = 135 mg/dL
07/06 4am = 136 mg/dL
***************************************
06/06 CT Scan
Hx: 2 mo. hx = jaundice, pruritus
endoscopy showed ampullary mas, adrenocarcinoma
(liver) = intrahepatic bile ducts mildly dilated
= hyperdense tubular structure with streak artifacts in the ampullary region
= atherosclerotic internal calcifications in the abdominal aorta
06/27 **guys, di ko sure kung blood to o urine...sorry...di ko pa rin nababasa...**
Total CHON 8g/dL
Globulin 3.9 g/dL
Na 136 mmol/L
** ciprofloxacin 500mg/tab also prescribed this day**
06/28 **eto, sa POS ko nakuha**
intermediate to high risk MI/ cardiac death from procedure
**ISMN 30mg/tab 1 tab OD prescribed this day**
the ff are (+):
hypertension(hpn) from may 2006
ampullary mass
occasional angina
PND **i looked it up and found it as Paroxsymal Nocturnal Dyspnea**
easy fatigability
palpitations
(fam hx) hpn in both parents
DM
the ff are (-):
syncope
asthma
PTB
allergies
thyroid disorders
**saka...non-alcoholic and non-smoker siya...**
**the client takes irbesartan 150mg OD for hpn**
07/01 Urinalysis
= light yellow
= sl. turbid
= pH 6.5
= sp. grav 1.015
= rbc 0-2 hpf
= pus cells 0-2 hpf
= squamous cells +
= bacteria ++
= urates ++++
07/04 Clinical Chemistry (specimen: blood which is A+)
= Na 145 mmol/L
= K 4.3 mmol/L <3.8-5>
= ionized Ca 1.23 mmol/L <1.18-1.3>
**normal naman lahat no? nakalimutan ko kung bakit kinuha ko pa to...**
CBC
= RBC 3.99
= RDW 12.6
= WBC 17.90
= segmenters 0.88
= lymphocytes 0.07
*************************
ADDITIONALS:
4 mos PTA
= jaundice, pruritus
= alcoholic stools, tea-coloured urine
= mild RUQ pain (PS about 2/10)
= consulted provincial hosp>> assessment: obstructive pain; advised further work-up
1 mo PTA
= UTZ>> obstructive biliary ductal tract disease
= rx>> ERCP **nasa MS book to** with stenting for relief
= biopsy>> ampullary adenocarcinoma (configured by CT Scan)
= advised surgery
! biopsy>> rubbery tissue fragments measuring a total of 1.3 x 0.6 x 0.2 cm
>> entire specimen taken
>> malignant neoplasm of branching glands lined by atypical cells with round to ovoid stratified hyperchromatic nuclei with little cytoplasm
ROS:
(+) headache
anorexia
wt loss
easy fatigability
cosntipation
(-) fever
hematamesis
melena
dysuria
***************************************************
NURSE'S NOTES 07/06
= NGT-GD yellowish output minimal output
= indwelling catheter draining yellowish output
= jejunostomy tube left nostril **ganyan yung nakasulat dun pero mali diba? sa jejunum nga yung JT eh...o ako lang yung naduling?**
= epidural cathether
= post-op dressing dry and intact
= may not reinsert NGT and JT if accidentally pulled out **di ko lam kung bakit?**
