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IM Worksheet CHOLECYSTITIS
IM Worksheet CHOLECYSTITIS
REPRESENTATIVE CASE
1) IDENTIFYING DATA: A. R., 53 years old, male, married, Filipino, businessman, born on May 1, 1957 from Manjuyod,
Negros Oriental.
2) CHIEF COMPLAINT: Right Upper Quadrant Pain
3) MEDICAL HISTORY
Patient claims complete childhood immunizations. He has no known food and drug allergies. He is a known
hypertensive with maintenance medication of Losartan 50mg 1 tab OD (Diagnosed November 30,2020). He is non-
diabetic and non-asthmatic. No previous surgeries and previous hospital admissions.
C)FAMILY HISTORY:
Patient has no heredofamilial diseases at the maternal side. Patient has a family history of hypertension and
arthritis from the paternal side. He is the 3rd child among 7 children. His first and fourth siblings has arthritis.
D)PERSONAL AND SOCIAL HISTORY:
Patient is a non-smoker and an occasional alcohol-containing beverage drinker consuming 1-2 bottles of beer on
special occasions with his last intake on November 19, 2020. His diet is mostly composed of red meat pork and rice.
Patient manages his business during most of the day. He claims no illicit drug use and no recent travel history.
V. THERAPEUTIC MANAGEMENT
LIST OF PROBLEMS THERAPEUTIC OBJECTIVES
PHARMACOLOGIC MANAGEMENT
DRUG NAME EFFICACY SAFETY SUITABILITY
P-DRUGS
DRUG NAME EFFICACY SAFETY SUITABILITY COST
JUAN DE LA CRUZ MD
REFERENCES:
Silliman University Medical Center
JUAN DE LA CRUZ MD
Lic. No. 0123456