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    Castillo Justification Letter Floria

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    docgilbert

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    © All Rights Reserved
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    Castillo Justification Letter Floria

    Uploaded by

    docgilbert
    3 views1 page

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    castillo justification letter Floria

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    3 views1 page

    Castillo Justification Letter Floria

    Uploaded by

    docgilbert

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    To: ANTONETTE Q.

    DIMAANO, MD FPOGS
    Licensing Officer V
    Chief – RLED

    Letter of Explanation

    This is a case Floria Tabor 80years female present residing at Lubang island, with the chief of General
    Body weakness. Last February 19, 2024 at 11:24am

    Initial Diagnosis of at the hyperglycemia crisis, Community acquired pneumonia moderate risk,
    hypertension stage II, acute uncomplicated cystitis.

    At the ER upon CBG reveled high, because of this patient was advised for admission. All laboratory was
    requested. And admitted at the ward.

    Review of system

    + vomiting 3x per bout, - chest pain – difficulty of breathing + orthopnea

    Initial Assessment: chronic coronary syndrome, DM type 2 uncontrolled, infection process to be


    determined.

    Treatment and management were done by Dr, Ramirez MOIII resident on first hospital day start given
    Ceftriaxone 2 gram/IV, Azithromycin 500mg tab OD, Omeprazole 40mg IV OD, on the 2 nd hospital day
    patient was referred to IM service due to uncontrolled blood sugar on February 20, 2024 at 7pm. And
    patient still lethargic and sugar range high  457mg/dL  422mg/dL. urinalysis revealed DKA since
    we don’t have ABG for metabolic acidosis, clinically patient Kussmaul Breathing. With this finding
    patient to consider DKA secondary to active infection. Plus, ketone in urine upon assessment DKA in
    moderate status. Because of this Immediate management this patient first controlled blood sugar given
    insulin 70/30 and rapid insulin given, potassium correction side effect of insulin hypokalemia 2.76 and
    proper hydration of this patient. On the 3 rd hospital day sugar controlled at 180mg/dl with good urine
    output patient is conscious coherent not in distress and potassium corrected at 3.9. no subjective
    complaint. February 21 -24 clinically improves patient condition. We plan to transfer this patient since as
    internist and patient is manageable. Also relative refused to transfer to tertiary hospital. All medication
    was given and advised to continue meds at home. After 1 week up follow patient sugar was controlled
    and CAP resolved and UTI complicated are complete resolved…

    Thank you

    “The good physician treats the disease; the great physician treats the patient who has the disease”

    Dr. Castillo Gilbert


    Internist

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