ABARCA AND ABAYA

1. Mr.Caspe 68, has been confined to bed with casts on both his legs. He seems angry and has stated that he does
not want to talk to anyone. You’re aware that he has fight with his nephew. His VS reveals, BP 150/100mmhg, PR
68 cpm, RR 15cpm, T 37.3C. He was did not participate in his physical therapy session in the morning since he
verbalizes that it will not help him get well. He is a known diabetic but non-compliance to his medication his recent
RBS is 140mmol/dl. He is currently on Apidra 6 units before meals ( for his DM) and Lozartan 50mg 1 tablet once a
day in the morning ( for his hypertension)

ALVARADO AND ASUNCION

2. Mr. Dizon, 48, M was admitted to the medical ward due to Community Acquired Pneumonia as confirmed by his
Chest Xray result. He reports shortness of breath. Upon initial assessment his VS reveals BP 150/100mmhg, T
38.5C, PR 59bpm, RR 20cpm, O2 saturation of 90%, crackles can be heard all over lung fields. His past medical
history revealed that he is a smoker and an occasional alcoholic beverages drinker. He also complains of loss of
appetite this past few days prior to admission. He is also concern on going back to work right after discharged.

BONCALES AND BLANCO

3. Mr Vincenzo is 68 years of age and was admitted to the aged care facility two days ago. Mr Bonnici speaks little
English. He refuses to take his medications and is spending a lot of time lying on his bed. When approached by a
staff member he speaks rapidly and loudly. Mr Bonnici has a reddened area at the base of his spine and his right
elbow. He is overweight, has mild right sided weakness from a stroke (Cerebral Vascular Accident - CVA) mobilizes
independently with a frame and has a history of severe right sided shoulder pain. He has had no bowel actions
since entering the facility.

BUNAO AND DAJAC

4. C.S. is a 78 year old PT admitted to the nursing home unit with a diagnosis of dehydration. C.S. has been ordered
to increase their PO intake to 2500 cc/day. When offering her a glass of water she pushes away your hand and
says, “I hate water and don’t drink it much.” You note that after one and a half days she has dry mucous
membrane and poor skin turgor.

CORROZ AND DURAN

5. S.D. is a 50 year old male who has just been admitted for nausea, vomiting, and diarrhea. He has an IV. You enter
the room and notice that his emesis basin is full of vomitus. He has had a large watery bowel movement in the
bedpan and tells you he feels dizzy. The PT has poor skin turgor, is hypotensive BP 90/60, with dry mucous
membranes.

DAQUIAOG AND ESTRADA

6. A patient is admitted with complaints of shortness of breath, chronic cough with thick ,copius amounts of
sputum, loss of appetite and fatigue. He states that these symptoms have become worse within the last 2 months.
He is 45 yrs old and smokes cigarettes.

FADRIQUELA AND GERALDOY

7. Mr. Garcia is a 53-year-old man with abdominal pain with PS of 7/10 who arrives at the ER with his wife Scarlet.
He’s also complaining of nausea and vomiting. He’s the vice president of a major corporation and smokes a pack
and a half of cigarettes a day. His BP reading is 140/100mmHg
GUILLANO AND HABOC
8. Sam Street is a 62-year-old African-American male who presents to his new family medicine physician for
evaluation and follow-up of his medical problems. He generally has no complaints, except for occasional mild
headaches and some dizziness after he takes his morning medications. He states that he is dissatisfied with being
placed on a low sodium diet by his former primary care physician. He reports a “usual” chronic cough and
shortness of breath, particularly when walking moderate distances (states, “I’m just out of shape”).

HOW AND JABADAN

9. Five days PTA, Mr. Hobbs had become nauseated and did not feel like eating. Although the nausea resolved after
a couple of days, he began to have diarrhea, which led him to continue his avoidance of food intake. Mr. Hobbs
purchased a commercially available rehydration solution from his local pharmacy and attempted to drink the small
but frequent volumes recommended by his pharmacist, but he could not keep up with fluid losses. The diarrhea, in
conjunction with increasing fatigue and lack of substantial fluid intake for 2 days, prompted his physician to
hospitalize him for further evaluation.

JOSE AND LAUS

10. Madison Bradley is a 29-year-old woman who presents to the ED for an acute visit due to shortness of breath
since awakening this morning. She states she especially becomes short of breath when she exercises; although she
admits that her shortness of breath is not always brought on by exercise and sometimes occurs when she is not
actively exercising. Upon auscultation wheezing can be heard. She has no complains of chest pain or fever.

LIBERATO AND LUZA

11. Patient R.S.B., a 33 year old Filipino female was admitted last March 8, 2020 with an admitting diagnosis of T/C
acute calculus cholecystitis with a chief complaint of abdominal pain. A day prior to consultation, the client noticed
persistent of pain on her abdomen specifically on the right upper quadrant. Whole abdominal ultrasound was
done. The said diagnostic revealed that her gallbladder cholesterolosis/mucosal polyp, hence laparoscopic
cholecystectomy. Pre operatively, she was given Nubain 1/2 amp throuh IV and ciprofloxacin tablet. Post
operative, she was given Tramadol 100mg slow IV push Q8 and Ketorolac 30mg IV Q6.

MAGANTE AND MAGNANAO

12. Patient M.A.V. a 57 year old American woman was rushed to the ER due to abnormal uterine bleeding. She had
an admitting diagnosis of Abnormal Uterine Bleeding (AUB) secondary to Endometrial Polyp, Polycystic Ovarian
Syndrome (PCOS). She has had Diabetes Mellitus and Hypertension 20 years ago. Days after her confinement, she
was scheduled for Fractional Dilatation and Curettage. Pre operatively, she was given Ranitidine 1 amp slow IV
push and Metoclopromide 1 amp. Post operatively, she was given Tranexamic Acid 500mg capsule TID and
Cefuroxime 500mg tab TID.

MANTABOTE AND MARFORI

13. Client A.V.P. a 58 year old male was admitted due to severe dizziness. Few minutes prior to admission, he
experienced dizziness with association of nausea and vomiting. At the emergency room, his BP was 150/100 and
was given Catapres 75mg sublingually, after an hour his BP was rechecked= 90/70. He was also given
Metoclopromide 1 amp through IV. His initial diagnosis was Benign Paroxysmal Positional Vertigo. During
confiment, he was being given Cinnarizine 25mg TID. Plain cranial CT scan was done but with normal results. 

MERCADO AND NITURA

14. Patient C.M.B. a 7 year old male was rushed to the ER together with his mother due to cough. 5 days prior to
confinement, patient experienced non productive dry cough. He had fever for 3 days and was relieved by
Paracetamol. Few hours prior consult, persistent cough was evident hence, admission. He was admitted under the
diagnosis of Bronchial Asthma with Acute Exacerbation (BAIAE). Chest Xray was done and the result was Basal
Pneumonia on right lung. Nebulization of Salbutamol+Ipratropium Q4 was given with Methylprednisolone 15mg IV
Q6. Before discharge, his doctor gave him prescription for Fluticasone+Salmeterol 125mcg MDI to be continued at
home.

OLYMPIA AND PADDISON

15. Patient E.M.K. was admitted in the hospital with a chief complaint vomiting. She is an 8 year old Filipino female.
1 day prior to consult she had a high grade fever (38.3 C) and was given Paracetamol but few hours before
confinement, she vomited ingested food three times. She was also complaining of throat pain with pains scale of
8/10. Upon assessment, oral mucosa was dry, eyeballs were sunken, and tonsils were hyperemic. She was
admitted with the initial diagnosis of Acute Gastroenteritis (AGE) with moderate signs of dehydration. During
confinement, Cefuroxime was 750mg IV Q8 was administered, together with Omeprazole 20mg IV OD. Stool exam
was done with result and no intestinal ova/parasite was seen. 

PABTI AND PE BENITO

16. Patient F.C.M a 2 year old female was rushed to the ER with her mother due to vomiting with association of
body weakness, hence consult to ER. She was diagnosed with Intestinal Amoebiasis with moderate dehydration.
Fast drip 140cc of D5LR was ordered. Fecalysis was done ad result showed Entamoeba Hystolytica was detected,
hence Metronidazole 105mg IV Q8 was started. CBC was also done. All result was normal except for her WBC=12.2
(normal value=4.5-10).

REOMALES AND ROSAL

17. M.B.S is 49 year old female patient who was admitted last August 6, 2018 at around 5:14 pm. She was
diagnosed with Type II Diabetes Mellitus, uncontrolled with the chief complaint of body weakness. 3 days before
admission, an increase on her blood sugar was noted at 400 mg/dl with positive dizziness. Different laboratory
tests were ordered upon admission. Urinalysis was also ordered. Her urine’s color was yellow and hazy. Glucose
and protein were also seen on her urine. FBS was at 24.09 mmol/l which is higher than the normal level of 3.89-
5.49. Cholesterol levels were high at 7. 56 mmol/l, triglycerides were at 2. 87 which was higher than <1. 69 mmol/l,
HDL was below normal (1.13 mmol/l), LDL was higher than normal (5.11 mmol/l), and cholesterol/ HDL ratio was at
6.69 mmol/l which is higher than <4.52 mmol/l.
Patient M.S.B. received different medications which include:
• Metformin 1g BID (after meals)
• Atorvastatin 40mg ODHS
• Vitamin B Complex 1 tab OD
• Xelevia 100mg OD (after lunch)

ROSENDE AND SANTILESIS

18.  E.R. is a 44 year old male patient who was admitted last July 29, 2018 at around 8 am. He was diagnosed with
“t/c fluid overload probably secondary to heart failure vs. chronic kidney failure” with the chief complaint of
bipedal edema, grade 2+, about 3- 4 mm depression that disappears for about 5- 10 seconds. “Namamanas yung
dalawa niyang paa” as verbalized by the client’s wife. There was no skin impairment (other than the edema) and
his movement was slightly limited. Active range of motion can be done but weakness on upper and lower
extremities was faintly observed. He has type II diabetes mellitus for almost 10 years now n. Complete blood count
was requested upon admission and results of his haemoglobin (94g/l), haematocrit (0.27), and red blood cells
(3.54) were reported lower than their normal ranges. His white blood cells (13.3) and platelet (351) were higher
than the normal levels. Potassium levels of the patient were lower compared to the normal range (3.5- 5.3mmol/l)
with the value of 2.08 mmol/l. His creatinine level was 355 μmol/L which is higher than the normal level of 62- 115
μmol/L.
The client received different kinds of medications for different purposes. 
- Furosemide 4 mg TID 
- Glimepiride 3mg BID
- Losartan 100mg OD after breakfast
- Omacor I cap TID
- Atorvastatin 80 mg ODHS
- Kaligen (Potassium Chloride) 2 tabs QID
- Ketosteril 2 tabs TID
- Spironolactone 25 mg 1 tab after breakfast or lunch

YACAT AND SEVA

19. Pt. C.R.D ,2 y/o female, was rushed to the Emergency room by her mother due to high grade fever of T39C and
productive cough. 4 days prior to confinement the mothered notice loss of appetite and body weakness. Upon
admission her diagnosis is Pediatric community Acquired Pneumonia (PCAP). Venoclysis was started with D50.3
NaCl x 67-68ugtts/min. Complete Blood Count was done and revealed WBC 11.0 (NV 4.5-10.0) & Segmenters 0.72
(NV 0.50-0.70). Urinalysis revealed RBC 3-6/hpf & Pus Cells 2-4/hpf. Chest Xray result consider Pneumonia.
Medications:
Cefuroxime 350mg IV q8hrs ANST
Salbutamol nebule 1 neb q 6hrs
Paracetamol 150mg IV q4 hrs for T>38.5C
Paracetamol 120mg/5ml, 6 ml p.o q 4hrs for T>37.8C
GUIDELINES:
1. 1 PROBLEM PER PAGE
2. FOLLOW THE FORMAT ABOVE
3. IN THE ASSESSMENT COLUMN ONLY THOSE SUBJECTIVE OR OBJECTIVE DATA THAT SUPPORTS YOUR DIAGNOSIS
SHOULD BE WRITTEN. Ex.. Pain Scale if your diagnosis is pain
4. If you don’t have a collaborative intervention leave it as is
For the rationale, what will be written is ANO ANG MAGAGAWA NG INTERVENTION MO PARA MASOLVE ANG
PROBLEM NG PATIENT.. Ex.. TSB for fever the rationale is it decrease temperature by process of evaporation and
conduction. If medication write the mechanism of action of the meds
5. EVALUATION WILL BE WRITTEN IN FUTURE TENSE Ex. The temperature will decrease from 38 to 37 after 30
minutes of intervention