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  • Date Submitted: 10/10/2010 06:45 AM
  • Flesch-Kincaid Score: 60.4 
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West Visayas State University
College of Nursing
La Paz, Iloilo City

    I. Vital   Information
Name: N.Y. Date of Interview: October 1, 2010
Age: 56 Informant: Patient herself; F.Y.
Sex: Female Relationship to patient: Daughter
Address: Zone 3 Baldoza, La Paz, Iloilo City
Civil Status: Widowed
Date and Time Admitted: September 29, 2010; 3:30 p.m.
Chief Complaint: Difficulty of Breathing
Ward: Female Medical Service Ward
Bed No.: 2
Allergies: No known allergies to drug, food and other environmental allergens.
Religious Affiliation: Roman Catholic
Physician: Dr. S.
Impression Diagnosis: DM Nephropathy Azotemia 2° CAP-MR UTI, DM 2
Pre-op Diagnosis: N/A
Post-op Diagnosis: N/A
Surgical Operation performed: N/A
Days Post-op: N/A

    II. Clinical Assessment
      1.   History of present illness
          a. Usual Health Status

          Aside from her diabetes, N.Y occasionally feels weakness and fatigue upon too much exertion and activity around the house. She claims to rest and lie down for relief. She also experiences the usual colds and flu and is relieved by self-medicating, usually paracetamol 500 mg/tab, 1 tab per day and applies efficascent oil for relief of muscle pain.

          b. Chronologic Story

          2 months prior to confinement, the patient developed a non-pitting edema on both legs from the knee down. She experienced a decrease in her pain sensation. She had increased her fluid intake by as much as twice than normal, especially before going to sleep. She also increased her food intake by as much as twice than normal but she had weight loss, the amount of weight loss however was not remembered and she easily gets tired. No consultation was made. She, at that time, was taking her maintenance medications, which were; Acarbose (Glucobay), 50mg/tablet three times a day, taken before meals and metropolol (Tartrate), 100mg/tablet once a day. There was no compliance for these medications however....

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