Beruflich Dokumente
Kultur Dokumente
I. Patients Profile
Name: Age: Sex: Address: Religion: Occupation: Attending Physician: Date of admission: Date of discharge: Mrs. R.D 57 years old Female 36 Luna Street, Lapaz, Iloilo City Roman Catholic Housewife Dr. F.M December 12, 2012 still on admission during data gathering.
Right Flank Pain Nephrolithiasis with moderate hydronephrosis and hydroureter secondary to obstructing proximal ureterolithiasis, right. Human Albumin Transfussion57cc 25% CVP Insertion
Special procedures:
Operative Procedure:
Hypertension -on telmisartan + amlodipine 40/5mg, stopped last August 2012. Bilateral Nephrolithiasis - on potassium citrate, stopped last August 2012.
General Assessment
Awake, conscious and coherent, dressed in clean and comfortable clothing, conversant with folks. With vital signs upon assessment of: T-36.7 C CR-118bpm RR-26bpm BP-140/80mmhg
4.1 Head- normocephalic, symmetrical and smooth. Absence of depressions, masses and scars. Hair is smooth, colored gray and evenly distributed. 4.2 Face- oval shaped, absence of pimples, acne and scars. Edema, disproportionate structures and involuntary movements not noted.
4.3 Eyes- anicteric, symmetrical, inline with each other, non-protruding and equal palpebral fissures. Pupils are equally round, reactive to light and accomodation.
4.4 Nose-located symmetrically on the midline of the face, absence of swelling, lesions, perforations and discharges. With pinkish nasal mucosa. 4.5 Ears- aligned with the outer canthus of the eyes, symmetrical and no discharges nor perforations noted. 4.6 Mouth- dry lips and oral mucosa. Tongue in midline of the mouth. Tooth decay noted on right canine and frontal teeth. No halitosis noted.
4.7 Neck- head is in central position. No deformities, lesions nor limits in range of motion. Lymph nodes are non-palpable. 4.8 Chest- symmetrical, no masses, lesions nor retractions noted. 4.9 Heart- tachycardic, adynamic precordium. 4.10- Abdomen- uniform in color, no scars nor lesions noted. Tenderness noted on hypogastric and epigastric area.
4.11Genitalia- not assessed, but patient complains of dysuria and urinary frequency.
4.12 Upper extremities- equal in size and length. No deformities, lesions nor scars noted, able to perform full range of motion. 4.12 Lower extremities- both legs are edematous ( plus 2 pitting edema), unable to perform full range of motion exercises. Still with full pulses.
Laboratory Results
Laboratory Data
December 12, 2012
Hematology Hemoglobin Hematocrit RBC Count WBC Count Differential Count Neutrophil Segmenter Stab Lymphocyte Platelet Count Result 103g/L 0.34 vol. fr. 5.18 x 10/L 19.53 x 10/L 93% 85% 8% 6% 72.0 x10/L Normal Values M: 130-180 g/L F: 120-160 g/L M: 0.40-0.54 vol. fr. F: 0.37-0.47 vol. fr. M: 4.6-6.2 x10/L F: 4.2-5.4 x10/L 4.5 -11.0 x 10/L
December 12, 2012 Urinalysis Color Results Pale straw Normal Values Light yellow -amber
Transparency Reaction
Specific Gravity Microscopic Findings Puss cells RBC Chemical Tests Sugar Albumin
Hazy Acidic
1.030 50-60 2-4 Negative Trace
Clear Acidic
1.005-1.035 None None Negative negative
December 12, 2012 ABG pH paCO2 pO2 HCO3 O2 saturation Results 7.41 28.8 mmhg 73 mmhg 18.8 mmol/L 95.7% Normal Values 7.35-7.45 35-45 mmhg 80-100mmhg 22-26 mmol/L 95-100%
Chest PA Impression :
Decemberv13, 2012
Ultrasound Report Impressions: Diffuse fatty liver Nephrolithiasis, with hydronephrosis and hydroureter Normal gallbladder, pancreas, spleen, left kidney and urinary bladder.
December 13, 2012 Results FBS (Fasting Blood Sugar) 9.55 mmol/L Normal Values 4.1-5.9 mmol/L
Uric Acid
497.54 umol/L
155-357 umol/L.
December 14, 2012 Miscellaneous Report Prothrombin Time % Activity: 80% Patient: 14.8 seconds INR: 1.15 Normal Values 70-10% 11.6-16.0 seconds
Results 22.55 g/L 13.14 mmol/L 155.59 umol/L 140.28 mmol/L 3.39 mmol/L
Normal Values 34-50g/L 2.5- 6.40 mmol/L 53-88umol/L 136-146 mmol/L 3.5- 5.1 mmol/L
December 16, 2012 ABG pH paCO2 pO2 HCO3 O2 saturation Results 7.38 31 mmhg 80 mmhg 18.3 mmol/L 95% Normal Values 7.35-7.45 35-45 mmhg 80-100mmhg 22-26 mmol/L 95-100%
Drug Study
Nephrolithiasis
Large stones
tiny stones
Large stones
Tiny stones
Altered nutrition less than body requirements related to nausea and vomiting. Risk for decreased cardiac output related to severe acidosis.
Risk for infection related to invasive procedures. (Urinary catheter, CVP insertion.)
Risk for injury related to decreased RBC production. Risk for impaired skin integrity related to edema. ( 2+) Knowledge deficit regarding condition related to information misinterpretation
Updates on Nephrolithiasis
Home remedies from herbal teas and grocery foods dissolve kidney stones and reverse renal failure October 31, 2012 by: JB Bardot
Lemonade Apple cider vinegar Cranberry juice Parsley and dandelion Marshmallow root buchu
lemonade
Cranberry juice
Marshmallow roor
Buchu
When claudin-14 is idled, the kidney's filtering system works like it's supposed to. Essential minerals in the blood like calcium and magnesium pass through the kidneys and are reabsorbed back into the blood, where they are transported to cells to carry out basic functions of life. But when people eat a diet high in calcium or salt and don't drink enough water, the small RNA molecules release their hold on claudin 14. An increase in the gene's activity prevents calcium from re-entering the blood, the study shows.