Ward II-PPA Case Study Presentation

A Case study of M.D., 38 years old, female, diagnosed

with Papillary Thyroid Carcinoma S/P Total
Thyroidectomy and Multiple Uterine Myoma S/P Total
Abdominal Hysterectomy with Bilateral Salpingectomy.
INTRODUCTION

UTERINE MYOMA

DEFINITION
Uterine myoma are noncancerous growths of the uterus that often appear during
childbearing years. Also called leiomyomas (lie-o-my-O-muhs) or fibroids, uterine
myoma aren't associated with an increased risk of uterine cancer and almost never
develop into cancer. Many women have uterine myoma sometime during their lives.
But most women don't know they have uterine myoma because they often cause no
symptoms. In those that do, symptoms can be influenced by the location, size and
number of myomas. Rarely, a myoma can cause acute pain when it outgrows its
blood supply, and begins to die.
Myomas range in size from seedlings, undetectable by the human eye, to bulky
masses that can distort and enlarge the uterus. You can have a single fibroid or
multiple ones. In extreme cases, multiple myoma can expand the uterus so much
that it reaches the rib cage. Myomas are generally classified by their location.
Intramural myomas grow within the muscular uterine wall. Submucosal myomas
bulge into the uterine cavity. Subserosal myomas project to the outside of the uterus.

The growth patterns of uterine myomas vary. They may grow slowly or rapidly, or
they may remain the same size. Some myomas go through growth spurts, and some
may shrink on their own. Many myomas that have been present during pregnancy
shrink or disappear after pregnancy, as the uterus goes back to a normal size.
Myomas usually don't interfere with getting pregnant. However, it's possible that
myomas, especially submucosal myomas could cause infertility or pregnancy loss.
Doctors believe that uterine myomas develop from a stem cell in the smooth
muscular tissue of the uterus (myometrium). A single cell divides repeatedly,
eventually creating a firm, rubbery mass distinct from nearby tissue. Doctors may
discover myoma incidentally during a pelvic exam or prenatal ultrasound

CAUSES
• Genetic changes
• Hormonal imbalance

RISK FACTORS
• Heredity
• Race
• Environmental factors
SIGNS AND SYMPTOMS
• Heavy menstrual bleeding
• Prolonged painful menstrual bleeding
• Pelvic pressure or pain
• Frequent urination
• Difficulty emptying the bladder
• Constipation
• Backache or leg pains
• Spotting or bleeding between periods

COMPLICATIONS
• Anemia
• Placental abruption
• Fetal growth restriction
• Preterm delivery

DIAGNOSTIC STUDIES
• Ultrasound
• Blood test
• Complete blood count (CBC)
• Magnetic resonance imaging (MRI)
• Hysterosonography
• Hysterosalpingography
• Hysteroscopy
TREATMENT

Medications
Medications for uterine fibroids target hormones that regulate your menstrual cycle,
treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don't
eliminate fibroids, but may shrink them. Medications include:
• Gonadotropin-releasing hormone (Gn-RH) agonists
• Progestin-releasing intrauterine device (IUD)
• Tranexamic acid (Lysteda)

Other medications
• Oral contraceptives or progestins
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
Surgical Procedures
Surgical procedures are done to remove the myomas to prevent reccurence. surgical
procedure include:

Noninvasive procedure
MRI-guided focused ultrasound surgery (FUS)is a noninvasive newer technology
treatment option that s performed while inside an MRI scanner

Traditional surgical procedures

Options for traditional surgical procedures include:
• Abdominal myomectomy
• Hysterectomy
THYROID CANCER

DEFINITION
Thyroid cancer occurs in the cells of the thyroid. A butterfly-shaped gland located at
the base of the neck, just below the Adam's apple. The thyroid produces hormones
that regulates heart rate, blood pressure, body temperature and weight.

Most cases of thyroid cancer can be cured with treatment.Thyroid cancer typically
doesn't cause any signs or symptoms early in the disease.It's not clear what causes
thyroid cancer but it occurs when cells in the thyroid undergo genetic changes
(mutations). The mutations allow the cells to grow and multiply rapidly. The cells
also lose the ability to die, as normal cells would. The accumulating abnormal
thyroid cells form a tumor. The abnormal cells can invade nearby tissue and can
spread throughout the body.
Despite treatment, thyroid cancer can return, even if you've had your thyroid
removed. This could happen if microscopic cancer cells spread beyond the thyroid
before it's removed. Thyroid cancer recurrence most often occurs in the first five
years after surgery, but it can recur decades after your initial thyroid cancer
treatment.

TYPES OF THYROID CANCER

The type of thyroid cancer determines the treatment and prognosis. Types of thyroid
cancer include:
• Papillary thyroid cancer. The most common form of thyroid cancer,it arises from
follicular cells, which produce and store thyroid hormones. Papillary thyroid
cancer can occur at any age, but most often it affects people ages 30-50.
• Follicular thyroid cancer. It also arises from the follicular cells of the thyroid. It
usually affects people older than age 50.
• Medullary thyroid cancer. This begins in thyroid cells called C cells that produce
the hormone calcitonin. Elevated levels of calcitonin in the blood can detect
medullary thyroid cancer at a very early stage.
• Anaplastic thyroid cancer. A rare and rapidly growing cancer that is very difficult
to treat. Anaplastic thyroid cancer typically occurs in adults age 60 or older.
• Thyroid lymphoma. A rare form of thyroid cancer that begins in the immune
system cells in the thyroid and grows very quickly. Thyroid lymphoma typically
occurs in older adults.

RISK FACTORS
Factors that may increase the risk of thyroid cancer include:
• Female sex
• Exposure to high levels of radiation
• Certain inherited genetic syndromes
• Family history
SIGNS AND SYMPTOMS
As thyroid cancer grows, it may cause:
• A lump that can be felt through the skin on your neck
• Changes to your voice, including increasing hoarseness
• Difficulty swallowing
• Pain in your neck and throat
• Swollen lymph nodes in your neck

COMPLICATIONS
Thyroid cancer may recur in:
• Lymph nodes in the neck
• Small pieces of thyroid tissue left behind during surgery
• Other areas of the body’
DIAGNOSTIC STUDIES
Tests and procedures used to diagnose thyroid cancer include:
• Physical exam
• Blood tests
• Fine-needle biopsy
• CT Scan
• Ultrasound
• PET
• Genetic testing
TREATMENT
Your thyroid cancer treatment options depend on the type and stage of your thyroid
cancer, your overall health, and your preferences.

Surgery
Most people with thyroid cancer undergo surgery to remove all or most of the
thyroid. Operations used to treat thyroid cancer include:
• Removing lymph nodes in the neck.
• Thyroid lobectomy
• Thyroidectomy
Medication and Therapies include:

• Thyroid hormone therapy

• Radioactive iodine
• External radiation therapy
• Chemotherapy
• Targeted drug therapy
Targeted drugs used to treat thyroid cancer include:
• Cabozantinib (Cometriq)
• Sorafenib (Nexavar)
• Vandetanib (Caprelsa)
These drugs target the signals that tell cancer cells to grow and divide. They're used
in people with advanced thyroid cancer.
ANATOMY AND PHYSIOLOGY
Reproductive System

The female reproductive system includes the

ovaries, fallopian tubes, uterus, vagina, vulva,
mammary glands and breasts. These organs are
involved in the production and transportation of
gametes and the production of sex hormones.
Functions
• Produces gametes (oogenesis)
• Receive sperm from the male
• Serve as site for fertilization
• House and nurture developing embryo then later, fetus
Ovaries
• Female gonads
• Paired, almond-shaped organs about 1.5 in (4cm) long
• Located on either side of the uterus in the pelvic cavity
• Produces female sex hormones such as estrogen and
progesterone as well as ova (commonly called "eggs"), the
female gametes.
Fallopian Tubes
• Paired, hollow tubes, each measuring 4 in (10 cm) long
• Have no direct contact with the ovaries; instead, it opens to the
peritoneal cavity
• Lateral end faces an ovary and its medial end connects w/ and
opens into the uterus
• Conveys the ovulated secondary oocyte from the ovaries to
the uterus
• Provides a place for fertilization of the secondary oocyte by
sperm
Uterus
• Hollow, thick-walled organ which lies in the pelvic cavity, anterior to the
rectum and posterosuperior to the urinary bladder
• Shaped like an upside-down pear about 3 inches long and 2 inches wide
by 1 inch deep (7.5 cm x 5 cm x 2.5 cm)
• Serves as a pathway for sperm deposited in the vagina to reach the
fallopian tubes
• “womb”
• Site of implantation of a fertilized ovum, development of fetus during
pregnancy and labor
• When no implantation occurs, there will be menstruation

Vagina
• tubular canal that extends from the exterior of the body to the cervix
• situated between the urinary bladder and rectum
• the receptacle for the penis and semen during sexual intercourse, the
outlet for menstrual flow and passageway for childbirth
• “birth canal”
The Endocrine System
• System of glands and hormone-secreting
cells that regulate body functions through
chemical messages called hormones
• Controls and integrates the functions of
other organs in the body
• Together with the nervous system, it is a
major regulator of homeostasis
Thyroid Gland
• Butterfly-shaped organ on anterior neck
• Located below the larynx (voicebox) and
anterior and lateral to the trachea
• ISTHMUS: narrow, central portion of thyroid
gland dividing it into left and right lobes
• THYROID FOLLICLES: microscopic sacs that
make up most of the gland
• FOLLICULAR CELLS: cells in walls of the
follicles that secrete T3 and T4
• PARAFOLLICULAR CELLS: lie between the
follilces and produce calcitonin
Thyroid Gland Hormones

T3 (Triiodothyronine) and T4 (Thyroxine)

• Produced from iodine
• Stimulus: release TSH from anterior pituitary
• Target cells: various body cells
Effects/ response:
• High ATP production  high basal
metabolic rate  increased energy
consumption from all food types and
increased oxygen consumption
increased body temperature
• Increased rate of protein synthesis
(maintains normal growth and development
together with growth hormone)
Secretion of T3 and T4
• Decreased metabolic rateand decreased T3 AND T4 in
the blood stimulates release of TRH from hypothalamus
• TRH is carried along hypophyseal portal veins
• TRH stimulates anterior pituitary gland to secrete TSH
• TSH is released into circulation
• TSH stimulates follicular cells of thyroid gland to secrete
T3 and T4
• T3 and T4 is released into circulation and increases
metabolic rate
• Elevated levels of T3 and T4 inhibit release of TRH and
TSH
Calcitonin
• Important for calcium homeostasis
• Stimulus: hyperkalemia or increased calcium levels in
blood
• Target cells: osteoclasts and osteoblast
• Actions: inhibits osteoclast to lower bone resorption
• : stimulates osteoblasts to increase calcium
deposition from the blood to the bones
• Response: calcium levels of blod is decreased and
returns to normal
• Negative feedback: calcitonin release is inhibited and
once calcium levels in blood return to normal
• Normal
• Papillary Thyroid Carcinoma
ClIENT IN CONTEXT

M.D., 38 years old, female, Filipino, Roman Catholic, residing

in Daanbantayan, Cebu was admitted for the 1st time in
CVGH last February 27, 2017 at 2 o’clock in the afternoon
accompanied by her husband via wheelchair, for complaints
of constipation and palpable mass in the lower abdomen.
Patient was scheduled for TAHBS (Total Abdominal
Hysterectomy, Bilateral Salpingectomy) on February 28, 2017
due to multiple uterine myoma and was admitted in PPA 231
with a case number of 041501 and hospital number of 17-
97167 in the Department of OB/Gyne under Dr. Yvette
Rochelle-Garcia, M.D.
HISTORY OF PRESENT ILLNESS

1 year PTA, patient experienced constipation for 1 week and upon

palpation she felt tender, mobile, hard and firm mass about the size
of an orange in the lower abdominal area. Patient seeks consult and
ultrasound revealed multiple myoma. Patient was advised to have
surgery but patient was lost to follow-up.
1 week PTA, patient experienced heavy menstrual bleeding,
frequent urination, back pain, and constipation and managed by
taking Dulcolax. Patient observed mass has increase in size, sought
consult and ultrasound revealed multiple uterine myoma. Appraised
for surgery on February 28, 2017 thus, current admission.
PAST HEALTH HISTORY

Patient had 1 hospitalization and surgery before at Seamen’s

Hospital last 2012 due to Papillary Thyroid Carcinoma. Patient
is S/P Total Thyroidectomy and currently maintaining
Levothyroxine (Euthyrox) 100mg OD and Thydine 12.5 mg OD
taken with good compliance.
Patient is non hypertensive, non-asthmatic, non diabetic. Patient
is allergic to NSAID (Ibuprofen). Patient had previous anesthesia
without any difficulty encountered.
Heredofamilial diseases inlude hypertension and asthma on
paternal side, and brain tumor on maternal side. Patient’s one
sister has ovarian cyst and she also had another sister with
myoma.
I. HEALTH PERCEPTION - HEALTH MANAGEMENT PATTERN

Patient defines health as being able to do the things she needs to

do. Patient claimed that she is non-alcoholic beverage drinker
and non-smoker. Self-medication practices include Saridon for
headache, Neozep forte for common cold. Herbal medicine
includes Buak Merah Juice and she takes Enervon C sometimes
when feeling so tired. Patient submits herself for a health check-
up only for health problems but had X-ray and Urinalysis yearly.
Patient couldn’t recall her childhood immunizations and only
received Tetanus vaccine when she was pregnant.
Patient is an elementary teacher for 15 yrs with a fixed workshift in
an average work hour of 8 hours per day from 8 AM to 4 PM.
Patient had employment benefits such as sick leave, vacation leave,
maternity leave, and health insurance include PhilHealth and CFI.
Patient stated that she is very satisfied in her job since this what she
wants to do.
 Patient lives in their own house for 5 years in a 1-storey wood
house with 3 doors, 5 windows, 2 bedroom, 1 kitchen, 1 dining
room, 1 living room, 1 comfort room which needs minor repairs.
The crowding index is 3 which indicates that there is household
crowding. Their electricity is provided by CEBECO. They have the
flush type of toilet and have a closed drainage. They use distilled
water for drinking and water pump for general household use
without undergoing water purification Their garbage is collected
once a week by the barangay’s garbage collecting unit and
sometimes by burning the garbage. She stores her medications in
a medication kit but sometimes they put it in the refrigerator.
Their house is approximately 2 minutes on foot from the main
road, 5 minutes by car to the grocery store, pharmacy, and
hospital, 3 minutes by car to the church, and 15-20 minutes on
foot to the heath center. Their usual mode of transportation is
via private vehicle. Patient’s husband claimed that they felt
safe in their neighborhood since they know most of their
neighbors there. There are no nearby factories around the
area they are living.
Patient claimed that their income is adequate for food, water,
housing, medications and other healthcare expenses and is
satisfied with her economic status
FAMILY GENOGRAM
II. NUTRITIONAL - METABOLIC PATTERN

MEAL 24-Hour Diet Recall USUAL DIET

Breakfast Time last taken: 7 AM Usual Time: 6:30 AM
Meal Taken at: Hospital Meal: 1 cup rice, egg, hotdog and
water
Meal: Bread and water
Lunch Time last taken: 11:30 AM Usual Time: 6:30 AM
Meal Taken at: Hospital Meal: 1 cup rice, vegetable, water
Meal: Fish, rice and water
Dinner Time last taken: 7 PM Usual Time: 7:00PM
Meal Taken at: Hospital Meal: 1 cup rice, fish, vegetable,
water
Meal: Soup, fish, rice and
water
 Patient usually takes her meals with a bit of condiments. Patient
stated that she drinks about 5-6 glasses of water per day, and
drinks 1 cup of coffee sometimes and drinks milk every night before
she sleeps. She drinks carbonated beverages about 3 times a
week. She prefers burger and hotdog, she does not want seafoods
but is not allergic to it. Patient claimed that she has a good apetitie
and does not follow a particular diet and no restrictions were
imposed. She usually eats with her family at home with home-
cooked meals and only eat fastfoods once a week. The patient is
the one who shops their food but it is prepared by their helper. She
stores food placed in a Tupperware in the refrigerator and serves it
on a glassware. Patient reads food labels especially the expiration
date. She doesn’t have any food supplements.
 During hospitalization, patient was placed on NPO post-
midnight pre-op and NPO post-op and only had sips of
water. Patient claimed that she had 3 episodes of non-
projectile vomiting with watery vomitus amounting to ½
cup per episode a few hours after surgery. She was on soft
diet except milk, milk products, or carbonated beverages
on one day post-op (March 1) and had full diet by lunch at
two days post-op (March 2).
Patient neither has dentures nor dental appliances. She
brushes her teeth 3 times a day but doesn't floss. She
sometimes rinses with an oral antiseptic.
III. ELIMINATION PATTERN

Patient stated that she defecates once a day with a brown sausage-
shaped, but lumpy stool. Last year she usually experinced
constipation and uses suppository (Dulcolax) as a laxative to
manage it. During hospitalization, patient stated that one day
after surgery she defecated a black-ish stool and was able to
pass out flatus without difficulty.
Patient urinates frequently with a clear, yellowish urine
amounting to 1 glass per urination about 6-7 times a day. During
hospitalization, patient urinated an average amount of 700 ml for
March 1 and March 2 for 8 hrs with light yellow colored urine. She
doesn't have an ostomy and did not submit herself for colorectal
cancer screening.
IV. ACTIVITY-EXERCISE PATTERN

Patient usually wakes up during weekdays at 6AM, goes to work by

7 am, go home during lunch with her children, goes back to school at
1PM and goes home at 4:30 PM. During weekdays, patient wakes
up at 8 am and does household chores such as doing the laundry,
and sweeping. During free time, patient usually spends her time
playing with her children or watching movie. She doesn't use an
assistive device and is able to perform the activities of daily living.
She is not enrolled in a formal exercise program and considered
walking from school to home and vice versa everyday as her
exercise.
After surgery patient is usually in bed because she complaints
of intermittent pain at the incision site with a pain score of 5/10
(with 10 as the highest) occuring at rest and aggravates when
 V. SLEEP-REST PATTERN

Patient wakes up at 6 AM and usually sleeps at 9-10 PM. She also

spends about 8 hours of sleep a day and does not take a nap in the
afternoon. Patient prefers no light, silent, and slightly cold
environment when she sleeps using 1 pillow and a blanket. Patient
had difficulty in sleeping in 2012 for 1 month because she
experiences palpitations due to her Papillary Thyroid Carcinoma
and uses sleeping pills so she can sleep. But it has now resolve
after her operation Total Thyroidectomy.
During hospitalization, patient had a good sleep but she is awaken
when the nurses visit to her room for procedures and V/S taking.
 VI. COGNITIVE-PERCEPTUAL PATTERN

Patient speaks Cebuano, Tagalog, and English but prefers to speak

Cebuano. Patient’s highest educational level is a college graduate, a
BS Elementary Education graduate. She is oriented to time, place,
person and circumstance. When asked about what she know
about her present illness, she verbalized “Kahibalo nko ani last
year pa naay tumor sa ako uterus, mabatian man nko, pero
karon ky okay naman, happy raman pd ko naa nman koy duha ka
anak”.
Patient has reading glasses since 2011 although she couldn’t
recall her grade and her the last eye exam.
Patient also claimed that her ability to taste and smell has not
changed ever since. Patient is without a hearing aid and that there
VII. SELF PERCEPTION - SELF CONCEPT
PATTERN

When asked to describe herself patient just smiled and laughed

and verbalized “ayaw lang na nga question miss” but patient stated
that she is satisfied with herself and is happy about their present
state of living. She has a positive outlook even after the surgery
since she has her husband always at her side and she has her
family to support her.
ROLE-RELATIONSHIP PATTERN

Ecomap
She has 2 children, a boy and a girl. Patient’s family is nuclear. Her role
in the family is the financial manager, and the child-rearer. She does
not only assume these roles but she is also a coordinator and
harmonizer as claimed by her husband. The ones responsible for
making decisions on daily household expenses, discipline, health
matters and household activities is the patient and her husband. For
child-rearing activities, the patient is the one in-charge. As stated by the
patient, decisions are made through communication. They are not
facing any conflicts within the family and if there are conflicts, the
husband and the patient solve it right away. She stated that there was
no change in her relationship with her family and friends during her
hospitalization.
IX. SEXUALITY-REPRODUCTIVE PATTERN

Patient’s sexual preference is heterosexual, and she is sexually

active. She was 27 years old when she had her first sexual
contact, and her last sexual contact was 2 weeks prior to
admission. There were no problems with her sexual activites as she
claimed. Patient does not use any contraceptives and has no sexually
transmitted infection.
Patient had her menarche at 13 years old and her last date of
menstrual period was at February 10, 2017. Her mentrual cycles
occurs on a regular schedule for 3-4 days and uses 3 fully soaked
pads per day and does not use tampons. She experienced heavy
menstrual bleeding 1 week prior to her consultation.
 Patient has been pregnant 2 times and has 2 daughter. All of her
children are living, and she had no problems or complications with
her pregnancies. Her obstetrical score is G2P2002. She was 28
years old when she was pregnant with her first daughter and
delivered NSVD attended by doctor in St. Vincent’s Hospital. She
was 33 yrs old when she was pregnant with her 2nd daughter
delivered NSVD by a doctor in VCMC. Patient claimed that she
submitted herself for regular prenatal check-ups during her
pregnancy.
X. COPING-STRESS TOLERANCE PATTERN

Patient defines stress when her students at school is very noisy

and naughty but she is able to manage her stress well.
Whenever she has problems and is stressed out, she usually
prays to God for guidance and provision. To relive tension and
stress, she talks to her husband about it.
XI. VALUE-BELIEF PATTERN

The values that the patient considers important include “mag-

amen” and respecting elders, which she passed on and taught
to her children. Patient and her family have no cultural or
spiritual beliefs or practices, and her religious practices include
going to church on Sundays. Patient owns a rosary and a
novena, but she does not pray them often.
Physical Examination
Day 1 March 1,2017 (8:00 AM)

MEASUREMEN BMI IBW

TS:62 inches;
Height: CATEGORIES
<18.5: Underweight CATEGORIES
<70%: Severe malnutrition
70-80%: Moderate malnutrition
18.5-24.9: Normal
157.48 cm :
25-29.9: Overweight
: Mild malnutrition
80-90%:
Weight: 58 kg; 127.6 lbs 90-110%: Ideal Weight
30-34.9: Obese Class 1 110-140%: Mild obesity
BMI and interpretation: 35-39.9: Obese Class 2 140-200: Moderate obesity
23.3, Normal >40: Obese class 3
>200% Morbid obesity
IBW: 50.10 kg
GENERAL APPEARANCE:
Seen patient lying on bed, alert, responsive, afebrile and coherent with IVF
Challenge
bottle 2 D5LR11L at 30 gtts/min infusing well at left arm with the following
vital signs:

BP: 120/ 80 mmHg

PR: 82 bpm
RR: 18 cpm
TEMP: 36.2 C

.
 Light hair brown with
evenly pigmented skin.
Slightly moist, smooth,
SKIN: warm to touch, good
mobility and turgor, no
edema noted.
 Fine and evenly
distributed, straight,
black colored hair. Scalp
SCALP & HAIR: is clean and dry with no
lesions and lice
infestation.
 Pinkish nail beds. Nails
are clean and well-
trimmed, hard, smooth
and firm. Nail plate is
NAILS: firmly attached to nail
bed. Clubbing of nails
not noted.
 Eyes are symmetrically
aligned in sockets without
protruding or sinking.
Eyebrows are the same with
hair color, symmetric and
HEAD & FACE: evenly distributed. Eyelids
closes and opens fully,
eyelashes are short, same
with hair color, and evenly
spaced. Bulbar conjunctiva
is clear, moist and smooth
with tiny vessels visible.
 Sclerae is slightly white.
Palpebral conjunctivae are
pinkish on both eyes, moist
and free from swelling and
lesions. Puncta is visible
HEAD & FACE: without swelling or redness,
no tenderness or drainage
noted but with minimal
lacrimation. Cornea is
transparent, moist. Both
lens are clear. Both iris are
round and uniform in color.
 Pupils are equally round and
reactive to light and
accommodation (PERRLA).
Positive corneal light reflex,
reflections of light noted at same
HEAD & FACE: spot on both eyes. Uncovered
eye remains fixed while covered
eye does not move as cover is
removed during covering test.
Full extraocular movements, both
eyes move in a smooth and
coordinated manner.
 Patient is able to identify
primary colors found in the
room and is able to read
student nurse’s cover of the
notebook as written as “king
jim, lil’ notebook” within 3 ft
HEAD & FACE: (distant vision). Patient is
able to read student nurse’s
nameplate written as “Aileen
Cabasag” at 12 inches
distance (near vision).
 Equal in size bilaterally
about 6cm. Pinna is in
line with lateral canthus
of both eyes; earlobes
are free. External ears
EARS & HEARING: are smooth without
lesions and lumps or
nodules, color consistent
with the facial color and
no discharges noted;
non-tender auricle and
mastoid process.
 Small amount of moist,
yellow cerumen was
noted on both ears. Both
tympanic membranes
are shiny and pearly
EARS & HEARING: gray. Patient is able to
hear whispered word
“sunshine” on the right
ear and “velez” on left
ear within 2ft.
 Color is consistent with the
rest of the face, smooth
and symmetric without
tenderness and
NOSE & SINUSES: discharges noted. Able
to sniff and blow through
each nostril while other
is occluded. Nasal
mucosa dark pink, moist
and free of exudates.
 Nasal septum is at midline,
intact and free of ulcers
or perforations. Clear
NOSE & SINUSES: frontal and maxillary
sinuses upon
transillumination and are
non-tender to palpation
and percussion.
 Lips are moist, pinkish
without lesions or
swelling. Yellowish teeth
present and patient has
no dental appliance.
Gums are pink, moist
MOUTH & PHARYNX: and firm with tight
margins to the teeth, no
lesions, redness, and
swelling noted. Buccal
mucosa is pinkish,
smooth and moist
without lesions.
 Tongue is moist, pinkish at
midline without lesions,
nodules or
fasciculations, papillae
MOUTH & PHARYNX: present on dorsal
surface; ventral surface
smooth and shiny
pinkish with small visible
veins present, frenulum
in midline.
 Smooth, pink and moist
soft palate, no lesions
noted. Uvula is pinkish,
moist, hangs freely in
midline without redness
MOUTH & PHARYNX: or exudate. Tonsils are
pink, symmetric without
exudates and swelling.
Gag reflex is intact.
 Symmetric with head
centered and without
bulging masses. Thyroid
cartilage, cricoid
cartilage move upward
asymmetrically as client
NECK: swallows. Range of
motion full, smooth, and
contracted. Trachea is in
midline. Thyroid gland is
not palpable when client
swallows. Lymph nodes
are not palpable.
 Scar noted 2cm above the
sternal notch area, 5cm
long horizontally
NECK: extending to the lateral
borders of the
sternocleidomastoid.
 Symmetrical in size.
Brown, round, symmetric
areola. No dimpling, no
retractions, no nipple
BREASTS: discharges and lesions
noted. No masses and
tenderness noted upon
palpation.
 Scapulae are symmetric, no
bulging, tenderness, or any pain;
symmetrical chest expansion.
Regular, effortless and quiet
breathing without use of
CHEST & LUNGS: accessory muscles. No
tenderness and crepitus noted.
No abnormal adventitious sounds
noted. Bronchial sounds were
noted over trachea,
bronchovesicular over major
sound over peripheral lung fields.
 Bronchophony as the patient
says “99”, soft, muffled and
indistinct sound was heard.
Egophony noted, a patient
says the letter “ee”, soft and
CHEST & LUNGS: muffled sound was heard.
Whispered pectoriloquy
noted as the patient
whispered “1,2,3”, muffled
sound was heard.
 Heaves are not noted. Apical
pulse at fifth intercostal
space, left midclavicular line
with a rate of 82 bpm.
HEART & PERIPHERAL Rhythm is regular. No thrills
VASCULATURE: or other unusual pulsations
noted. S1 sound is distinct
and heard best at the apex.
S2 sound is distinct and
heard best on the base. No
extra heart sounds and
murmurs noted.
 pinkish tone returns immediately to
blanched nail beds when pressure is
released.
CAPILLARY REFILL Upper extremities (R): pinkish; <2secs
(L):pinkish;<2secs
TIME: Lower extremities (R): pinkish; <2secs
(L): pinkish; <2secs
ALLEN’S TEST: right and left ulnar and
radial arteries are patent.
 a test for the patency of the radial artery after
insertion of an indwelling monitoring
catheter. The patient's hand is formed into
a fist while the nurse compresses the ulnar
ALLEN’S TEST artery. Compression continues while the
fist is opened. If blood perfusion through
the radial artery is adequate, the hand
should flush and resume its normal pinkish
coloration.

Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.

 Round and symmetric with
postoperative sutures noted
lining longitudinally from the
umbilicus up to mons pubis
around 12 cm long.
Umbilicus is at midline,
ABDOMEN: depressed and without
bulging, umbilical skin tone
is similar to surrounding
abdominal skin tone. Slight
aortic pulsations of the
abdominal aorta is noted.
Peristaltic waves not seen.
 Not assessed due to
RECTUM & GENITALIA patient’s refusal.
 Posture is erect without
exaggerated curvature of
cervical, thoracic or lumbar
spine. Can perform full
range of motion but slightly
difficulty in hips. Crepitus,
BACK & EXTREMITIES: fasciculations and bony
deformities are not noted.
No edema noted. Upper and
lower extremities are
symmetric.
MUSCLE STRENGTH:

MEASUREMEN SCALE:
TS: 5- full ROM against gravity; full resistance
5/5 5/5 4- full ROM against gravity; some resistance
3- full ROM with gravity
2- full ROM with gravity eliminated (passive motion)
5/5 5/5 1- slight reaction
0- no reaction
SPECIAL TESTS:
Phalen’s test: no tenderness noted on both wrist.
Challenge 1
(Phalen's maneuver is a diagnostic test for carpal tunnel syndrome)
Tinel’s Test: No tenderness, tingling sensation and numbness noted on both hands.
(Tinel's sign is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to
elicit a sensation of tingling or "pins and needles" in the distribution of the nerve.)
NEUROLOGIC ASSESSMENT:
 Awake, conscious, responsive,
oriented tome, place and person,
clothes appropriate or weather,
maintains good eye contact and
names familiar objects witho
MENTAL STATUS difficulty like house and window.
Client states husband’s name
“DEXTER” when asked, states
“HOSPITAL” when asked for the
place where she is and
“MORNING” when asked for
time.
 Client remembers and
answered the age when
she was pregnant with
her first child “27” and
confirmed by the
MENTAL STATUS husband. Client listens
and can follow directions
such as raising arm to
put the thermometer.
 Client can perform rapid
alternating movements
MOTOR/ without hesitation. Was
able to perform finger-
CEREBELLAR
thumb test on both
FUNCTIONS hands, heel-shin test,
can touch her nose with
her hand with eyes
closed. Client can stand
ambulate with minimal
support and assistance.
 Client can differentiate two
point discrimination, dull and
sharp objects on ar and
cheeks. Stereognosis:
correctly identifies object
SENSORY FUNCTIONS (ballpen).
Kinesthesia: correctly
identifies direction of
movements on both hands.
Graphesthesia: correctly
identifies numbers eight and
two on both hands.
 CN 1 (Olfactory): correctly
identifies the scent of coffee
CN 2 (Optic): Can read the
nameplate “Aileen C.
CRANIAL NERVE Cabasag” at 12 inches
TESTING distance.
CN 3, 4 and 6 ( Oculomotor,
Trochlear, Abducens): Full
extraocular movements,
PERRLA
 CN 5 ( Trigeminal): corneal
reflex present, clenches
teeth, identifies dull and
sharp sensations on
cheeks, forehead and
CRANIAL NERVE
chin.
TESTING CN 7 ( Facial): able to
smile, frown, wrinkle
forehead, show teeth,
puff out cheeks and raise
eyebrows.
 CN 8 ( Vestibulocochlear):
able to hear whispered
word “sunshine” and
“velez” within 2 ft
distance on both ears,
CRANIAL NERVE
was stable during
TESTING Romberg’s test with
minimal swaying as she
demonstrated the ability
to balance steadily with
eyes closed.
 CN 9 & 10 (Glossopharyngeal &
Vagus): uvula & palate rises
symmetrically when client says
“ah”, gag reflex present;
swallows without difficulty.
CRANIAL NERVE CN 11 (Spinal accessory): equal
TESTING shoulder shrug against
resistance.
CN 12 ( Hypoglossal):protrudes
tongue in midline, able to push
tongue depressor to left and right
side of the mouth without
difficulty.
 CN 9 & 10 (Glossopharyngeal &
Vagus): uvula & palate rises
symmetrically when client says
“ah”, gag reflex present;
swallows without difficulty.
CRANIAL NERVE CN 11 (Spinal accessory): equal
TESTING shoulder shrug against
resistance.
CN 12 ( Hypoglossal):protrudes
tongue in midline, able to push
tongue depressor to left and right
side of the mouth without
difficulty.
 Biceps: (R): +2
(L): +2
Triceps: (R): +2
(L): +2
DEEP TENDON
Brachioradialis: (R): +2
REFLEXES (L): +2
Patellar: (R): +2
(L): +2
Achilles: (R): +2
(L): +2
GRADING DEEP TENDON REFLEX:

SCALE:
+4 hyperactive, clonus, abnormal and indicative of a disorder
+3 active than normal but not indicative of a disorder
+2 normal, usual response
+1 decreased, less active than normal
0 no response
Day 2 March 2, 2017 (8:00 AM)

GENERAL VITAL SIGNS

APPEARANCE
Seen patient lying on
bed, alert, responsive,
BP: 110/ 70
afebrile and coherent. mmHg
PR: 88 bpm
RR: 20 cpm
TEMP: 36.4 C
LABORATORY EXAM RESULTS
 CBC (COMPLETE BLOOD COUNT)
Purpose: It is a basic screening test in order to
diagnose information about the hematologic
changes within the body system. It can also
help determine the number, variety, percentage,
concentration, and quality of blood cells.
COMPONENT RESULT NORMAL VALUE

WBC 15.3 10e3/uL 4.10-10.9

NEU 13.0 84.9% 2.50-7.50 47.0-80.0 %

LYM 1.17 7.67% 1.00-4.00 13.0-40.0 %

MONO 1.04 6.79% .100-1.20 2.00-11.0 %

EOS 0.035 .231% 0.00-.500 0.00-5.00 %

BASO 0.061 .401% 0.00-.100 0.00-2.00 %

RBC 4.08 10e6/uL 4.0-5.20

HGB 12 g/dL 12.0-16.0

HCT 35.3 .% 36.0-46.0

MCV 86.5 fL 80.0-100.0

MCH 29.4 pg 26.0-34.0

MCHC 34.0 g/dL 31.0-36.0

RDW 8.49 .% 11.6-18.0

PLT 258 10e3/uL 140.0-440.0

MPV 6.57 fL 0.0-99.9

 03/01/2017 5:01

Implication: A high white blood cell count

usually indicates an increased production of
white blood cells to fight an infection.
Neutrophils are a type of white blood cell that
help the body fight infection and heal injuries.
A low hematocrits means the percentage of red
blood cells is below the lower limits of normal
for that person’s age, sex, or specific
condition. A low RDW indicates a uniformity
in the size of your red blood cells.
 URINALYSIS
Purpose:Is a set of screening tests that
can detect some common diseases. It
may be used to screen for and/or help
diagnose conditions such as a urinary
tract infections, kidney disorders, liver
problems, diabetes or other metabolic
conditions.
MACROSCOPIC MICROSCOPIC

Color Yellow RBC/HPF 1-2/hpf

Appearance Clear WBC/HPF 1-2/hpf

Pathologic Cast (PAT)

Specific Gravity 1.015 Hyaline Cast (HYA)

Glucose Negative Epithelial Cells few/hpf

Ketone Yeast

Blood Mucous Threads few/hpf

Protein Negative Bacteria few/hpf

Bilirubin Others

Urobilinogen

Nitrite Urates few/hpf

 02/21/2017
2/21/2017
Implication: Mucus threads in urine are common
and thus are not reported as abnormal from a
urinalysis report. However, if the threads of mucus
are in excess, it could be an indication of a medical
problem. This could be an infection or
inflammation of the urinary tract. Urates form in the
urine if the urine pH is too acidic or basic, the
concentration of dissolved substances is high, or the
urine temperature leads to their formation at other
times it is due to the refrigeration process of urine.
X-RAY

X-RAY
Purpose: Is a common imaging test that views the inside of
the body without having to make an incision especially the
bony structures within the body and also the silhouette of
the different organ in the body.
02/20/2017
Radiologic Findings:
No radiographic evidence of active PTB. Heart and great
vessels are normal. Pulmonary vasculatures are within the
limits of normal. Costophrenic angles are clear. Other
chest structures are unremarkable.

Conclusion:
No significant chest finding
PROTHROMBIN TIME
PROTHROMBIN TIME
Purpose: It is a blood test that
measures how long it takes blood to
clot, this test can be used to check for
bleeding problems. PT is also used to
check whether medicine to prevent
blood clots is working.
 REFERENCE
RESULT
VALUES

CONTROL 13.0 seconds 10.5-13.0 seconds

PATIENT 11.9 seconds 10.7-14.7 seconds

INR: 0.92 0.90-1.3

% ACTIVITY 112.9% 90%-135%

 2/21/21017
Implication: The clients results all fits
in the reference values indicating that
her prothrombin time is normal.
IMMUNOLOGY-SEROLOGY
IMMUNOLOGY-SEROLOGY
Purpose: It is a laboratory
diagnostic that focuses on
identifying antibodies (proteins
made by a type of white blood cell
in response to an antigen, a foreign
substance, in the body).
 REFERENCE
TEST RESULT
MARKS

Thyroid Panel C

FT3 (ECLIA) 4.38 pmol/L 2.80-7.10

TSH (ECLIA) 1.540 uIU/mL 0.27-4.20

FT4 (ECLIA) 19.87 pmol/L 12.00-22.0

 02/22/2017
Implication: The results show that
the client’s immunology all falls in
the reference marks indicating it is
normal.
 BLOOD TYPING
Purpose: It is done so you can safely donate
your blood or receive a blood transfusion. It is
also done to see if you have a substance called
Rh factor on the surface of your red blood
cells.

Patients’s Blood Group: Group “O” Rh POS

Remarks: Blood typing waived
2/22/2017
ULTRASOUND
Purpose: It is a medical test that uses high-frequency sound waves to capture live images from the inside of your body and visualize organs and structures in details
02/08/2017
Reports
Uterus: 10.5x 9.8x 7.0cm retroverted (excluding M5)
Cervix: 3.7x 3.8x 3.7 cm without nabothian cyst
Endometrium: 1.1cm
Right Ovary: 1.8x 1.3x 0.6 cm
Left Ovary: 2.4x 2.3x 2.1 cm
Others: no free fluid in the cul-de-sac

Remarks:
The uterus is retroverted with irregular contour and inhomogeneous myometrium.
Within the uterus are well-circumscribed heterogenous structures suggestive of myopia uteri, described as follows:
M1=4.4x 4.0x 3.1 cm- anterofundal, intramural
M2=3.0x 2.8x 2.0 cm- posterior, intramural with subserous component
M3=0.7x 0.8x 0.7 cm- posterior, intramural
M4=0.9x 0.8x 0.8 cm- posterior, intramural
M5=9.4x 9.9x 8.0 cm- anterior, intramural with subserous component
The cervix is closed and homogenous.
The endometrium is thick and hyper echoic with intact endomyometrial interface.
Both ovaries are lateral to the uterus and contain small follicles.
There are no adnexal masses seen.
There is no free fluid in the cul-de-sac.

Impression
Enlarged retroverted uterus
Multiple Myoma UTERI, as described
Thick and intact hyperchoic endometrium
Normal both ovaries
No adnexal masses seen in this scan
No cul-de-sac fluid
 BLOOD CHEMISTRY
Purpose: A test that measures many
chemical substances in the blood that
are released from body tissues. It
helps evaluates a person’s general
health status, identify potential organ
damage, and evaluate the body’s
electrolyte balance.
EXAMINATION RESULT REFERENCE VALUES

FBS 92.88 70-110 mg/dL

CHOLESTEROL 193.52 up to 200 mg/dL

TRIGLYCERIDES 80.42 up to 150 mg/dL

HDL 54.48 >35 mg/dL

LDL 122.96 <150 mg/dL

VLDL 16.08 0-30 mg/dL

CREATININE 0.84 Male: 0.6-1.4 mg/dL

Female: 0.6-1.2 mg/dL

SGPT/AST 12.17 up to 41 U/L

MEDICATIONS
1. Cefoxitin 1g IVTT q8h
C: Antibiotics
A: Inhibits cell wall synthesis, promoting osmotic instability; usually bactericidal.
I: Serious infection of the respiratory or GU tracts; skin, soft tissue, bone, or joint
infection;bloodstream or intra-abdominal infection caused by susceptible organisms
- Perioperative prophylaxis
C: Contraindicated in patients hypersensitive to drug or other cephalosporins
- Use cautiously in patients with history of colitis, renal insufficiency, or seizures.
A: diarrhea, pseudomembranous colitis, N&V, acute renal failure, thrombocytopenia,
maculopapular and erythematous rashes, anaphylaxis
N: Tell patient to report adverse reactions and signs and symptoms of superinfection such as
fever, black hairy tongue, stomatitis, vaginal discharge, and foul smelling stools.
- Instruct patient to report discomfort at I.V. site
- Advise patient to notify prescriber about loose stools or diarrhea.
2. Chirocaine + Nubain 5-10cc IVTT q4h
C: CNS agent, local anesthetic; Opioid analgesic
A: Binds with opioid receptors in the CNS, altering perception and emotional response to pain.
I: Moderate to severe pain, adjunct to balanced anesthesia, local anesthesia for surgery and
obstetrics, and for postoperative pain management
C: Contraindicated in patients hypersensitive to drug
- Use cautiously in patients with history of drug abuse and in those with emotional instability, head
injury, MI accompanied by nausea and vomiting
- Due to the effects of opiate agonists on the gastrointestinal tract, this should be used cautiously in
patients with GI disease including GI obstruction, ulcerative colitis, or pre-existing constipation.
A: dizziness, headache, sedation, bradycardia, dry mouth, N&V, respiratory depression, hypotension
N: Drug should only be administered as a supplement to general anesthesia by those specifically
trained in the use of I.V. anesthetics
- Reassess patient’s level of pain at least 15-30 minutes after parenteral administration.
- Respiratory depression can be reversed with naloxone. Keep resuscitation equipment available,
particularly when giving I.V.
3. Parecoxib 40mg IVTT q12h
C: NSAIDS (Nonsteroidal anti-inflammatory drugs)
A: NSAIDs inhibit cyclooxygenase (COX) enzymes, which are involved in the synthesis of
prostaglandins and thereby reduce pain and inflammation. Oral NSAIDs are used post-operatively but
when patients are unable to tolerate oral medications or require a faster onset of analgesia, parenteral
administration may be preferred.
I: Indicated for the short-term treatment of postoperative pain in adults.
C: Patients with know hypersensitivity to Parecoxib
- Patients who have manifested allergic-type reactions to sulfonamides
- Active peptic ulceration or GI bleeding
- Inflammatory bowel disease
- Congestive heart failure
A: Constipation, abdominal pain, N&V, dizziness, insomnia, oliguria, pruritus
N: Watch for signs and symptoms of over and occult bleeding since NSAIDs cause an increased risk of
serious GI adverse events.
- Assess patient for CV risk factors before therapy
- Instruct patient to report any signs of adverse reactions such as nausea and vomiting, pruritus,
dizziness, etc.
4. Celecoxib 200mg/cap 1 cap q12h
C: NSAIDs (Nonsteroidal anti-inflammatory drugs)
A: Thought to inhibit prostaglandin synthesis, impeding cyclooxygenase-2, to produce anti-inflammatory,
analgesic, and antipyretic effects.
I: To relieve signs and symptoms of osteoarthritis, rheumatoid arthritis, and ankylosing spondilitis.
- Acute pain and primary dysmenorrhea
C: Contraindicated in patients hypersensitive to drug, sulfonamides, aspirin, or other NSAIDs.
- Use cautiously in patients with history of GI bleeding, advanced renal disease, dehydration, anemia,
and heart failure
A: headache, dizziness, pharyngitis, abdominal pain, diarrhea, dyspepsia, flatulence, GI reflux, back
pain, dyspnea
N: Watch for signs and symptoms of over and occult bleeding since NSAIDs cause an increased risk of
serious GI adverse events.
- Assess patient for CV risk factors before therapy
- Drug may be hepatotoxic; watch for signs and symptoms of liver toxicity
- Monitor patient’s renal function; renal insufficiency is possible in patients with preexisting renal disease.
5. Levothyroxine 100mcg/tab & 12.5mcg/tab 1 tab 30 mins AC (breakfast)
C: Thyroid hormone replacements
A: Stimulates metabolism of all body tissues by accelerating rate of cellular oxidation.
I: Thyroid hormone replacement, severe & long-standing hypothyroidism, myxedema coma
C: Use cautiously in patients with diabetes mellitus, diabetes insepidus, or myxedema and during rapid
replacement in those with arteriosclerosis.
- Contraindicated in patients hypersensitive to drug and in those with acute MI uncomplicated by
hypothyroidism, untreated thyrotoxicosis, or uncorrected adrenal insufficiency.
A: insomnia, headache, fever, tachycardia, palpitations, palpitations, diarrhea, vomiting, abdominal
cramps, menstrual irregularities, muscle weakness, dyspnea, heat intolerance
N: Patients with diabetes mellitus may need increased antidiabetic doses when starting thyroid
hormone replacement
- Patients with adult hypothyroidism are unusually sensitive to thyroid hormone. Start at lowest dosage,
and adjust to higher dosages according to patient’s symptoms and laboratory data until euthyroid state
is reached.
- Long-term therapy causes bone loss in premenopausal and postmenopausal women. Consider a
basal bone density measurement, and monitor patient closely for osteoporosis.
- Teach patient the importance of compliance to maintain constant hormone levels.
- Advise patient not to take OTC or other prescription drugs without first consulting prescriber.
6. Phospho-Soda 50ml + 1 glass of juice or gatorade (taken 2/27/17)
C: Saline laxatives
A: Sodium phosphate is a saline laxative that is thought to work through increasing fluid in
the small intestine by drawing water into the lumen of the gut, producing distention and
promoting peristalsis and evacuation of the bowel. It usually results in a bowel movement
after 30 minutes to 6 hours.
I: Relief of occasional constipation or bowel cleansing before medical procedures.
C: Congestive heart failure, renal failure, rectal bleeding, and dehydration
A: dehydration, dizziness, urinating less than normal, N&V, dry mouth, muscle weakness,
bloody stools
N: This should be administered on an empty stomach with a glass of juice.
- Monitor serum sodium and phosphorus levels.
- Monitor patient for adverse reactions such as dehydration, dizziness, N&V, etc.
- Long term use of this medication may cause dependence.
7. Esomeprazole 40mg/tab 1 tab (taken 2/27/17)
C: Antiulcer drugs
A: Reduces gastric acid secretion and decreases gastric acidity
I: Gastroesophageal reflux disease, to reduce the risk of gastric ulcers in patients receiving continuous
NSAID therapy, reduction of risk of rebleeding of gastric or duodenal ulcers after therapeutic
endoscopy
C: Use cautiously in patients receiving continuous NSAID therapy who are at increased risk for gastric
ulcers.
- Contraindicated in patients hypersensitive to drug or components of esomeprazole.
- Use during pregnancy only if potential benefits justifies potential fetal risk.
A: dizziness, abdominal pain, constipation, diarrhea, dry mouth, flatulence, N&V, pruritus
N: Monitor patient for rash or signs and symptoms of hypersensitivity. Monitor GI symptoms for
improvement or worsening.
- Antacids can be used while taking drug, unless otherwise directed by prescriber.
- Warn patient not to chew or crush drug because this inactivates the drug.
- Advise patient to store medication at room temperature in a tight container.
8. Metoclopramide 10mg IVTT q8h (taken 2/28/17)
C: GI stimulants
A: Stimulates motility of upper GI tract, increases lower esophageal sphincter tone, and blocks
dopamine receptors at the chemoreceptor trigger zone.
I: To prevent or reduce nausea and vomiting from caner chemotherapy, to prevent or reduce
postoperative nause and vomiting, GERD, adjunctive treatment of vasculare headaches
C: Contraindicated in patients hypersensitive to drug and in those with pheocromocytoma or seizure
disorders.
- Contraindicated in patients for whom stimulation of GI motility might be dangerous (those with
hemorrhage, obstruction, or perforation)
- Use cautiously in patients with history of depression, Parkinson’s disease, or hypertension
A: drowsiness, fatigue, seizures, suicidal ideation, dizziness, bradycardia, diarrhea, urinary frequency,
rash, loss of libidp, amenorrhea
N: Monitor bowel sounds.
- Monitor patient for involuntary movements of face, tongue, and extremities, which may indicate
tardive dyskinesia
- Advise patient not to drink alcohol during therapy
- Urge patient to report persistent or serious adverse reactions promptly
9. Omeprazole 40mg IVTT (taken 2/28/17)
C: Antiulcer drugs
A: Inhibits proton pump activity by binding to hydrogen-potassium adenosine triphosphatase, located at
the secretory surface pf gastric parietal cells, to suppress gastric acid secretion.
I: Erosive esophagitis, Pathological hypersecretory conditions (such as Zollinger-Ellison syndome),
Duodenal ulcer, short-term treatment of active benign gastric ulcer, frequent heartburn, stress ulcer
prophylaxis
C: Contraindicated in patients hypersensitive to drug or its components
- Use cautiously in patients with hypokalemia and respiratory alkalosis in patients on a low-sodium diet,
and in breast-feeding women
- Long term administrationof bicarbonate with calcium or milk can cause milk-alkali syndrome
A: dizziness, headache, abdominal pain, constipation, diarrhea, N&V, back pain, cough, rash
N: Caution patient to avoid hazardous activities if he/she gets dizzy
- Tell patient to recognize and report signs and symptoms of low magnesium levels such as
palpitations, muscle spasms, and tremors.
- Instruct patient to take drug at least 1 hour before meals.
- Tell patient to swallow tablets whole and not to open, crush, or chew them.
10. Tramadol 50mg IVTT (taken 3/1/17)
C: Analgesics
A: Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin.
I: Moderate to severe chronic pain
C: Contraindicated in patients hypersensitive to drug or opioids, in patients with severe renal
impairment, acute intoxication from alcohol, hypnotics, and centrally acting analgesics.
- Contraindicated in patients with significant respiratory depression or acute or severe bronchial asthma
or hypercapnia in unmonitored settings where resuscitative equipment isn’t available
- Serious hypersensitivity reactions can occur usually after first dose. Patients with history of
anaphylactic reaction to codeine and opioids may be at increased risk.
A: dizziness, headache, vertigo, seizures, anxiety, constipation, N&V, abdominal pain, diarrhea, dry
mouth, flatulence, urinary frequency, respiratory depression, diaphoresis, rash
N: Reassess patient’s level of pain at least 30 minutes after administration
- Monitor cardiovascular and respiratory status. Withhold dose and notify prescriber if respirations are
shallow or rate is below 12cpm
- Monitor for bowel and bladder function. Anticipate need for stimulant laxative.
- For better analgesic effect, give drug before onset of intense pain.
 DISCHARGE PLAN
Health Teachings:
• Instructed to verbalize pain
• Instructed to avoid strenuous activities
• Encouraged to eat foods rich in vitamins and mineral especially Vitamin C to boost immune system
• Instructed to prioritize activities and establish balance between activities and rest to prevent fatigue

Anticipatory Guidance:
• Instructed to attend follow-up check-up with biopsy results on March 10, 2017
• Informed patient and S.O. of signs and symptoms of infection such as fever, increased pain,
swelling, redness, and warmth around affected area so that they will come back immediately if they
will observe these signs and symptoms.
• Informed of the adverse effects of the medication like Celecoxib that they may manifest such as
headache, dizziness, abdominal pain, diarrhea, etc.
Spirituality:
• Advised to always trust in God and believe that He always has wonderful plans for each
and everyone of us.
• Advised to always be strong and optimistic in facing changes that she might encounter in
life.
• Encouraged to pray and read the Bible.
• Encouraged to go to church every Sunday or days of obligation.

Medication:
• Instructed to take full of course of prescribed medication (Celecoxib 200mg/cap 1 cap q8h
PO as needed for pain)
• Instructed not to take over the counter medications unless physician is consulted
• Instructed to take the right medication at the right dose, right time and right frequency
• Instructed not to skip medications and take the medications religiously
Incision:
• Instructed to perform wound dressing with betadine regularly
• Instructed to keep incision site clean and dry
• Instructed to do hand washing before and after cleaning the incision site
• Instructed to take a bath for hygienic purposes

Nutrition:
• Encouraged to eat foods rich in iron like: ampalaya, beans, broccoli, liver
• Encouraged to increase oral fluid intake
• Encouraged to eat foods rich in protein and vitamins to promote wound healing
• Encouraged patient to eat on time

Evironment:
• Encouraged patient to stay in a clean and well-ventilated environment
• Encouraged to maintain a conducive environment for sleep and rest
• Encouraged to place belongings within reach to preserve energy