DFCM Cell Phone: 09052642659/ 09228943434
Local Number: 2521
Hospice: 09276542185/09228943332
GP in: Michelle
ACR: Alex
SASOD: Ruby
AMBU AM: annie
PM: Grace
Pay Endorsement:
1. Complete admitting papers
2. CUT OFF BATCH 2014: 4PM
3. Philhealth CF3
Philippine General Hospital
University of the Philippines Manila
The Health Sciences Center
Taft Avenue, Manila
Department of Family and Community Medicine
Pay Ward Daily Patient Census
March 30-31, 2014
Rm #
702
700
568-5
568-4
553
552-2
552-1
454-1
436-2
406-2
CENICU 12
Dengue I (DF & DHF 1&II) 8k
Dengue II (DHF III&IV) 16k
Pneumonia I (MR) 15k
Pneumonia II (HR) 32k
Essential Hypertension 9k
Cerebral Infarct (CVA I) 28k
Cerebrovascular Accident (CVA II) 38k
AGE 6k
Asthma 9k
Typhoid Fever 14k
Newborn care package in hospital and lying in 1750
Dr. Tordesillas’ Clinic/Jesicca:: 524-0264
Rm 303 UDL Bldg. Taft Ave. (Sharmaine)
UPHS Mon PM (708-0000 loc 160)
FMAB schedule W-Th-Sat 1-4pm (Ava)
Philhealth# 1201-98122464
TIN # 141-719-845
Dr. Ang’s Clinic: 310 West-East Center, Taft
Avenue (beside KFC) 5281330 MW 9-4 F 1-4
FMAB T-Th 1-4pm; F 9-12 am
Philhealth #: 1201-0600628-6
Dr. Nicodemus’ Clinic: 310 West-East Center,
T aft Ave (beside KFC) 5281330
UPHSMon AM
Philhealth# 1201-0817470-0
Dr. Josefina Isidro
Philhealth #: 1201-9501621-0
UPHS Thurs PM
Dr. A.JB. Alip, Jr.
Philhealth #: 1201-9803950-0
Dr. Agnes Bausa-Claudio
Philhealth #: 1100-05010606
Dr. Doris Camagay
Philhealth #: 1201-9900024-5
Dr. Anna GuiaLimpoco
PhilHealth #: 1201-1225191-3
Dr. Karin Estepa-Garcia
Philhealth #: 1201-1121439-4
Dr. Pumanes (St. Paul) 5245687 loc 226
PhilHealth #: 1501-980-8329-5
DOH Hotline
711-1001 to 02
PNRC:
5270000 loc 0861
ASIAN Hospital:
771-9000
Makati Med:
888-8999
Manila Doctor’s Hospital: 5243011
Patient
Casing, Bonifacio
Fernandez, Karen Angela
Guiron Rolando
Terrenal, Romeo
Lachica Benjamin
Escalderon Danilo
Magno, Joeriz
Bandalan, Michael Shann
Pedraja, Gilda
Dimaculangan, Josefina
Matias, Cristeta
REFERRALS
Serra, Ignacio
Lachica, Benjamin
CO-MANAGEMENT
Rola, Eliezer
CI
Ronquillo, Milagros
Reyes, Remedios
TRANSFERRED
DISCHARGED
Manuta Buena
Arriesgado, Premitiva
MORTALITY
745
553
568-2
CI Bed 28 39
CI Bed 27 W2B28
606-2
416-6
Total no of patients
16
CENICU
Received
18
Primary
11
Discharged/TOS/HAA/HPR
2/0/0/0
Consultant
Limpoco
Tordesillas
Garcia
Ang
Ang
Tordesillas
Tordesillas
Limpoco
Tordesillas
Ang
Tordesillas
Ang
Ang
Bausa
Sianghio
Sianghio
Tordesillas
Limpoco
1
Transfer
1
Admission
0
New referral
0
Co-Managed/Referral
½
Hospice (CI)
2
Mortality
0
Employees
5
LCB 401-404:
3494
LCB 405-409:
3494 (524-9849)
LCB 410-412:
3492
LCB 413-418:
3492 521-9534
LCB 419-426:
3496
RCB 427-433:
3496
RCB 433-439:
3496 (523-3888)/3497
RCB 440-451:
3498 (447- 4504)/3499
452-500
3498
LCB 501-512:
3592
LCB 513-518:
3593 (526-0065)
LCB 519-536:
3594
RCB 537-553
3596/3597
RCB 554-565
3598
RCB 566-569
3599
RCB 601-644:
3696/3697/3698
RCB 645-649:
3696
RCB 650-659:
3698 (522-1801)
RCB 658-665:
3699
LCB700-713:
3792(522-2002)
LCB714-732:
3792
RCB733-763:
3796 (09154993391)
PGH TRUNKLINE: 554-8400
ACU:
2511/2517/2508
Admitting Section: 2067/ 567-3116
Ambu:
2514
Blood Bank:
3214
CENICU:
3252
CI:
4203
Chairman’s Ofc:
2522/2523
Col Public Health 525-5874
CT scan
3118
ECG:
3154
FMAB
7080000
FMC
5110
Lab Info/Hema
3209/3213
MRL:
3233
PACU:
3328
Radiology Info:
3106
UPHS:
2077 /2076
SHPM:
5302
TOX:
2311
2D Echo
3610
Billing:
2015/3132
Info:
2012
EHRO:
2064
702
CN 3526692
CASING, BONIFACIO
86/M
3/14: Michelle
Dr.
Limpoco/Dr.Anonuevo(CVS)Dr.Santiguel
(Pulmo)/Dr. Ong (GI)
CAP, LR
Hypertension
Hand Tremors prob sec Parkinsons with
depression vs. MDD
DOA right knee
CVS: CHF FC III sec to IHD, HHD
Consider chronic lung disease(COPD,
PTB w/ restrictive lung component)
Chronic AF w/ RVR
Pulmo:
Pneumonia in the elderly
COPD suspect
PTB
GI:
UGIB sec to
1. BPUD
2. ASA/warfarin induced
3. SRMI
Pneumonia in the elderly
Cor pulmonale
Chronic AF from ischemic heart disease
CC: DOB
IVF: PNSS 1l x 16h
HPI:
5 days PTA—(+) DOB, associated
with cough productive of yellowish
phlegm, no fever, no chest pain
noted.
4days PTA—consulted a private
MD where labs and CXR were
done. CXR showed pneumonia,
patient was given unrecalled
antbiotics and was advised
admission.
1 day PTA—seen by Dr. Limpoco at
FMAB—advised admission
Diet: low salt, low fat diet, 1 glass Nutren everyday
Sputum GSCS
Enterobacter cloacaecplx: S>
Meropenem </=0.25, Imipenem
0.5
Candida guillermondii: S>
Voriconazole </=0.12, Fluconazole
</=1, Amphotericin B 0.5
Antibiotics:
Meds:
NAC 600mg tab BID
Digoxin 0.25mg tab, 1 tab OD
Aspirin 80mg tab, 1 tab OD pc
Salbu + ipra neb q 12
Celecoxib 200 mg cap OD
Omep 40 IV q 12
Furosemide 40mg/IV post BT
Colchicine .5mg BID ---500mcg BID
Atorvastatin 40mg ODHS
Salmeterol+Fluticasone 250/25 1 puff BID
Ketoprofen gel BID
Discontinued:
Cefuroxime 750mg IV q8 D3+2
Azithromycitidn 500mg tab OD x 5 days D3
Pip Tazo 4.5g IV q8
NAC 200mg TID
Losartan 50mg tab, 1tab OD Hold
Carvedilol 6.25mg tab, ½ tab OD- Hold
Coumadin 1 mg/tab OD Hold
Folic acid + Ferrous Sulfate tab- HOLD
Voricozole 50mg/cap I cap BID D0+1
Meropenem 1 gm q8 D10 D/c
Omeprazole drip
CBC:
3/30: 115, 0.386/8.27/0.79/0.13/174
3/27: 63/0.203/7.772/209
3/25: 96/0.308/7.14/176/ S 7.14/L 0.18
3/23 144/0.457/6.93/0.76/0.17/0.05/0.02/193
3/20: 134/0.435/8.86/0.83/161
128/0.391/6.69/0.86/0.08/242
For EGD tom 7am
s/p 3u PRBc
(+) knee pain, (-) BM x 2 days
Post BT CBC
On nasal canula, comfortable
Blood Chem:
3/30 Uric Acid 0.29
Na 138 k 4.5 Cl 101 BUN 9.4 Crea 136
3/18 chole 158/TG 108/HDL 32/LDL 104/FBS
92/BUN 30.62/crea 1.24/Na 142/K 3.8
ECG: AF in RVR, RAD, LPHB, CRBBB, RVH, LVH,
old septal wall infarct
Still with knee pain
fundoscopy
Cataract bilateral with optic
disc sweeling. Cant sppreciate
other fidings
Still for otoscopy
CXR: official:multichanbered cardiomegaly,
likely to be secondary to mitral valve
pathology w/ pulmonary hypertension,
consider minimal pleural effusion, left vs
pleural reaction
Urinalysis
3/18 yellow,clear pH 5.5, 1.027, gluc(-),alb(tr),
RBC 0, PC 0
PT/PTT
3/30: 13.3/28.6/29%/2.61/30/44.1
3/25 PT 13.30/PT 27.7/% 30/INR 231
3/22: 13.3/17/62/1.36/29/35.8
3/18 : PT 13.3/15.7/72/1.24
PTT 29/79
Sputum AFB
Negative
Sputum GS
PMN > 100
Sq EC >100
Yc>25
Gram (-) bacilli >25
Gram (+) bacilli 2-10
Chest UTZ:
3/20:Left: Minimal pleural effusion, (-) safe
window (-) isoechoic complex over left
hemidiaphragm (consolidation vs mass); Right:
well aerated lung
(+) Depression symptoms
more than 5 based on the
depression scale
FF up:
Official CXR (repeat)
2D echo
Aortic stenosis, mild to
moderate with moderate
aortic regurgitation.
Concentric left ventricular with
segmental wall motion
abnormality and mildly
depressed global systolic
function. Increased right
ventricular dimension with
decreased contractility and
evidence of volume overload.
EF 50%
Continuing with possible C0r Pulmonale w CAD
700
CN 4018246
FERNANDEZ, KAREN
ANGELA
24/F
CC: fever
IVF: PNSS 1L x 8hrs --- D5NM 1L x 8hrs
HPI:
5 days PTA—(+) fevr associated
with headache. No abdominal pain,
bleeding episodes noted.
1 day PTA—consulted at FMAB,
CBC done showed low platelet
hence advised admission
DAT
Meds:
Paracetamol 500mg tab prn for fever
t/s Ceftriaxone 1g OD
ABG
3/29 7.454/46.4/81.6/32.3/8.696.2/34.2/32.3
3/25 7.491/49.3/102/38.5//13.7/98
3/19: 7.356/50.2/62.2/28.3/90.4
CBC:
3/30: 126, 0.395, 4.1, 0.54, 0.29, 0.15, 107
3/29 130. 0.397, 2.97, 0.64, 0.29, 108
129/0.378/115/3.24/0.57/0.34
Salmonella IgG and IgM: Non reactive
Dengue titers
IgG reactive, IgM non reactive
3/28: Michelle
48/M
Dr. Garcia/Janus Ong (GI)
3/29 Alex
PEG replacement
HIE sec to CP arrest
s/p tracheostomy
S/p PEG
HPN
For:
Repeat Salmonella Titer
Repeat CBC today pm (3/31)
Ff up Blood CSx2
Dengue Fever
GURION, ROLANDO
No bleeding episodes
Blood Chem
Na 135/K 3.6
Dr. Tordesillas
568-5
CN 388066
(+) fever episodes 38-40
CXR
Normal
Known case of HIE sec to CP arrest
S/p Tracheostomy
S/P PEG
HPN
3 days PTA, peg was removed
2 days PTA, patient was advised
PEG replacement, TPN was started
IVF : D5NM 1lX 8 hours
U/a
Yellow clear, blood +2, RBC 2, WBC 1, Bacteria
10, MT 3
CBC
128/.399/6.91/306/0.68
Diet: None for now, On TPN
Meds:
NAC 100mg/ml
Duovent neb now then 2x a day
Baclofen 20mg/tab
Carvedilol 6.25mg ½ tab once a day
Clopidogrel 75mg/tan OD
Senokot forte ODS
Calmoseptine aplle 2x a day
Dulcolax suppository
Tranexamic Acid tab q8
PT/PTT
13.30/14.3/ % 85 INR 1.1/APTT 30/ PTT 30
Awaiting dietary input
Awaiting Anes clearance prior
to discharge
Once with PEG to start
paracetamol 300mg /iv before
procedure then Paracetamol
300mgIV after procedure
Cbg: 126, 127, 165
568-4
CN 4018251
TERRENAL, ROMEO
53/M
3/28: Michelle
Dr. Ang/Dr. Lopez (GS3)/Dr. Sandoval
(Endo)
Acalcoulous cholecystitis
`DM type 2
CC: RUQ pain
IVF: PNSS 1L + 40meqs Kcl x 8hrs for 4 cycles
HPI:
5 days PTA – (+) RUQ pain 10/10,
no fever, no jaundice, no vomiting.
3 days PTA – admitted to a private
hospital. On UTZ (+) acalculous
cholecystitis, advised operation.
However decided to transfer to
PGH.
Meds:
Pip-Taz 4.5g IV q8
Demerol 2gmg IV q6
Omeprazole 40mg tab OD
Tramadol 50mg IV RTC x 24 hours
Paracetamol 600mgIVx1 dose
Buscopan 10mg IV q8
Glargine 14u q 24 --- 16 u q 24
Ca+Vit D OD
10% Oral KCl soln 30cc q 8h
Regular insulin 4 u TID pre meals
Cholangitis S/P Cholecystectomy
AKI on top of CKD sec to DM KD
Labs done outside:
Attached to chart
CBC
157/.530/13.27/187/0.66/.28
On going K correction
(+) improvement of upper
extremities weakness
(-) febrile episode
s/p Choleccystomy
Blood Chem
3/30: Na 148, K 2.0, Ca 1.90, Albumin 19, ALT
191, Crea 136
Hbaic 13.7/TB 67.3/DV 31.7/IB 35.6/BUN
11.6/Crea 118H/AsT 224/ALT 471/Alk Phosp
613/Amylase 244/Na 136/K 3.4
HA UTZ (c/o GS)
Emphyema GB with 0.9 cm hyperechoic foci
with definitive PSS
GB dilated
CBD non dilated
Ff up:
UA
CBG q 12 and HS
3/29
4-235, 8-303, 12-223
3/30/14
12- 173, 4 295
Monitor JP1 and JP2
CBG monitoring
173, 245, 285, 256, 272, 172
t/c Emphyema GB with acute cholecystitis
ABG: 7.364, 22.7, 95.5, 13.1, 9.7, 97.4
CXR
Bilateral TB infiltrates
Cranial CT Scan: initial unremarkable CT, no
bleed, no shift, polysinusitis
553
CN 4018197
Know case of PTB treated last
1993
IVF: PNSS x 16h consume then shift to D5NM x 16 h
Diet: DAT
LACHICA, BENJAMIN
56/m
3/26 ALEX
Dr. Ang
Pulmo mass prob malignancy
PTB r/o reactivation
Anemia of Chronic Disease
Pneumonia in ICH
Tinea faciae
HPI: Oct 2012 patient started to
have hemoptysis with cough
productive with dyspnea
2013, cough, dyspnea with
productive, wieght loss and
decrease appeptite
CXr and CT scan was done and right
pulmo mass 7x9x7cm w/
lymphadenopathy
Meds:
Pip-Tazo 4.5g IV q8 D5
Sincod forte TID
Tramadol + Paracetamol 37.5/325 q 6 RTC --- Tramadol 100mg tab
q6 RTC
MV + Iron OD
Buclizine
Fluconazole 200mg OD x 2 weeks
Nystatin oral solution TID x 5 days
Lactulose ---HOLD
Dexamethasone 4mg tab OD
Omeprazole 20mg OD
ECG
3/31: NSSTTWC can not rule out ischemia
Post op: NSSTTWC
RSR NPSSTWC
CBC:
3/29 105/0.349/651/30.19/0.89
80/0.30/26.40/812/
PT/PTT
PT 13, 15 % 73, 1.22
APTT 29/35
Blood Type: B+
Blood Chem
3/29: K 4.8
3/26: Na 130, K 3.2, Cl 95, RBS 100, BUN 6.18,
Crea 0.45, Alb 17, Ca 2.47, Mg 0.79 AST 27,
ALT 8, ALK phop 92.
s/p BT 2u PRBC
Referred to Hospice for
palliative care
Bedsore precaution
Discontinued:
Levofloxacin 500mg/tab OD
552-2
CN
ESCALDERON DANILLO
35/M
Dr. Tordesillas/Dr. Hernandez(ORL)
3/30 Alex
Multiple injury sec VA
Right zygomatic arch and latertal
orbitals fracutres
Impacted Cerumen, AS
CC: VA
IVF: PNSS 1l x16h
MOI: hit by a car and was drag
TOI: 11:45pm
DOI: March 21
Place: South wood
DAT
Admitted at laguna unconsicous,
work-up was done and revealed
fractures at facial area. Patient had
episodes of epitaxis and nasal
congestion hence admission
Meds
Celexocib 200mg/tab BID
Tramadol 50mg/tab q8
Na docusate 3 drops AU TID
Urinalysis:
Straw/clear/glucose trace/blood
+1/6.5/1.003/RBC 0/ WBC 4
CBC:
3/30: 129, 0.406, 9.16, 0.66, 0.24, 412
(-) chest pain
Urinalysis
3/30: yellow clear, alb normal, glu (-), pH 5.0,
SpGr 1.021, RBC 0, WBC 0, EC 0, Bact 44, MT
440
Blood Chem`
3/30: Na 136, K 3.9, Cl 103, BUN 4.6, Crea 75,
BUA 0.25, AST 30, ALT 42, Alk Phos 111, Alb
30, Ca 2.33, P 1.44, Mg 0.89
T-Cage:
Bone island vs pulmo nodule 5th posterior rib
left
ECG: RSR, NA, NSSTTWC
527
CN 4018279
NARAG, JIMMY
56/M
3/31: Michelle
Dr. Tordesillas/Dr. Lopez (GS III)/Dr.
Sandoval (Endo)
Calculous Cholecystitis
Complicated UTI
t/c DM type 2 with nephropathy
HTN St. II
552-1
CN 4018085
MAGNO, JOERIZ
37/M
3/25: Jen
Dr. Tordesillas/Dr. Grosman(Ortho
CC: RUQ pain
Cleared by Endo
For OR tom
HPI:
3 mos history of intermittent RUQ
oain.
1 week PTA – RUQ pain severe, no
fever, no jaundice, no vomiting.
HBT UTZ done showed distended
GB with cholecystitis. Advised
operation.
Referred to Philcare coordinator,
Dr. Tordesillas
Cc: leg pain both
IVF: Heplock
5 month PTA, patient with leg pain,
both, on and off, NPS 5/10 not
aggravated by activity relieved by
massage with tinglng sensation and
no limitation of movt no consult
and self med with unrecalled med
Diet: DM diet
Meds:
Metformin 500mg tab BID
Pregabalin 75mg tab OD HS BID
Celecoxib 200mg tab BID prn
Sitagliptin 50mg/tab once a day
CBC
??/0.437/9.53/0.68/276
U/A
Yellow orange/clear/6.0/1.031/+2 glu/+1
blood/RBC 0/WBC 0/bact 189/ CaOx 4/MT 686
Blood CHem
Na 138 K 3.4 Cl 102 Chole 5.33 Trigly 1.17 HDL
(+) leg pain 5/10
For rehab referral c/ Dr Mojica
for conservative managemtn
Spine)
Peripheral Neuropathy secondary to
DM neuropathy
DM type 2 NIR,NO
1 month PTA, increase frequency
and severity of bilateral leg pin, on
and off, NPS 10/10 with same
characteristic still with tingling
sensation no weakness no
limitation of movt hence consult
Tramadol IV PRN
Discontinued:
Gliclazide 80 mg tab OD
1.40 LDL 3.4 FBS 11.7 BUN 5.4 Crea 58 AST 15
ALT 25 alb 40 uric acid 0.20 Ca 2.33 Mg 0.77
HBA1c 10.6
Ortho:
Neurogenic claudication sec to
narrowed spaces L5-S1
CXR:
normal
LS xray:
retrolisthesis S1 over L5, degenerative osseous
changes
L5 radiculopathybsec to HNP
ECG: normal
MRI:
L5S1 HNP central causing mild to moderate
central foraminal stenosis
454-1
CN 4018253
BANDALAN, MICHAEL
SHANN
2/M
3/28: Michelle
Dr.Limpoco/Dr. Cu (Pedia)
AGE
UTI
CC: fever
IVF: D5LR 1L x 100cc/hr (FM + 30%) decrease to 70cc
CBC
3/29:
124/0.358.4.59.267.N .59/K .29/M .10
(-) febrile episodes
(+) coughing and bloatedness
(+) BM formed
HPI:
5 days PTA—fever Tmax 39.0C
associated with cough, colds and
sore throat.
Consulted a private hospital, given
Natravox and Paracetamol.
4 days PTA—noted LBM after
intake of NAtravox. Consulted a
private pediatrician, given
Metronidazole.
3 days PTA—still with LBM
consulted again a private hospital
however not admiited.
2 days PTA—noted vomiting and
dysuria, persistence prompted
consult and admission
DAT
Antibiotic::
Ceftriaxone 100 950mgIV q12 D1+2
Blood Chem
3/30: Na 136, K 4.2, Cl 102, BUN 2.1, Crea 50,
Ca 2.37
Meds:
PAracetamol
Simeticone 40mg/chew tab now
Salmonella titers
igG reactive
igM reactive
FFup
Blood CS x 1 site
Stool CS
Urine /CS
CXR
Fecalysis:
Brown, soft/mucoid RBC 0-2, WBC 2-5 NOPS,
Fat Globule 1+
Urinalysis:
Yellow, cloudy, 6.5, blood +3, glucose normal,
albumin trace, RBC 2, WBC 2, Bact 25, MT 30
Urine GS
PMN 0-1, gram + cocci in pairs
436-2
4018136
PEDRAJA, GILDA
41/F
3/23: Arvie
Dr. Tordesillas/Del Rosario (gyne)/Dr.
Cc: hypogastric pain
IVF: PNSS 1L x 12h
2 month history recurrent UTI by
UA, hypogastric pain radiating to
back 8/10, no vaginal discharge, (+)
dysuria, (-) hematuria, (-) oliguria,
(-) fever, (-) LBM. Given courses of
Ciprofloxacin and Unasyn with no
relief. Noted retroverted uterus
Antibiotic:
Ciprofloxacin 500mg tab 1 tab BID x 7 days D1
Medications:
HNBB 20mg IV q 8h PRN
Celecoxib 200mg BID - HOLD
Tramadol 50mg IV prn
Blood GS: (+) for G(+) cocci in pairs after 1536hrs of incubation
CBC
3/23
129/0.415/9.59/0.66/0.25/0.06/0.02/0.01/420
Blood chem.
3/23 Na 139/K 4.2/Cl 107/Chole 213/TG
98/HDL 37/LDL 157/FBS 98/BUN 11.80/crea
0.55/BUA 5.42/AST 26/ALT 29/alb 3.80/Ca
9.20/PO4 3.66/Mg 2.19
No hypograstic pain
MGH Uro and OB wise
Whole abd UTz:
3/24: Mild Fatty liver,
Cholecystolithiasis
Lapitan(Uro)
UTI
Myoma Uteri
Obese I
and myoma uteri on UTS and CT.
persistence of symptoms hence
admission.
Discontinued:
Ceftriaxone 1g IV OD D3
Urinalysis
3/23 yellow, clear pH 5.0, sg 1.022,gluc(-),alb(),RC 2,WBC 19
Urine GS:
PMN 0-1
Gram (+) bacilli 2-6
Gram (+) cocci 4-6
406-2
CN 4018180
DIMACULANGAN,
JOSEFINA
53/F
Cc: stroke with right residual
IVF: PNSS x KVO
24 days PTA, patient with sudden
weakness of the right side of the
body and sought consult at
Calamba Doctors with BP 240/120
and Dx with CVD bleed and
manage with unknown medication
Diet:OF feeding 1800 kcal
Dr. Ang/ Anlacan (neuro)
3/24: Jen
CVD bleed with right residual
HAP
HPN stage 2 uncontrolled
Neuro:
s/p ICH, L BG ~__ cc (3/1/14)
t/c HAP
HTN st II
Neuro:
CVA bleed L putamen
2 days PTA, patient was discharge
with right sided residual, unable to
ambulate and unable to talk with
home meds of cataprres, atenolol,
cefixine, flumucil and salbu neb
with unknown dosage and days of
treatment hence consult for
opinion and management
Antibiotics:
Piper-Tazo 4.5 gm TIV q 8 D6
Meds:
Flumucil NAC 600 ODHS
Salbu +ipra neb q 8 to consume stock
Paracetamol 300mg TIV q 4 prn
Paracetamol 500mg tab q 4 prn
Mannitol 50cc q 4h --- q6
Donepezil 5mg ½ tab OD
Captopril 25mg ½ tab OD PRN BP 160/100
Salb + Ipra neb q 8h
Carvedilol 6.25 mg tab BID
Fusidin ointment on bed sore q8
Telmisartan 80mg/tab
Amlodipine 5mg/tan --- 10mg OD
Omeprazole 40mg IV q 12h
Piracetam 1.2g TID
Discontinued:
Losartan 50mg tab OD  BID D/c
Transrectal UTZ
3/24: normal sized uterus with
small myoma uteri intramural
with subserous component,
normal ovaries with dominant
follicle, right
Proliferative phase
endometrium
Urine Culture
E.Coli S ceftriaxone
CT scan:
Myoma uteri
Right adexal cystic foci, likely
ovarian in origin
Renal cyst L Bosniak
CBC
135/0.40/12.3/463
(-) coffee ground material per
NGT
For referral to Rehab/Dr.nacio
once cleared by neuro
BP range 140-160/90-200
U/A
Yellow, turbid, RBC 150/WBC 200/ EC
1/Bacteria 500
Blood CHem
Na 138 K 4.6 Cl 101 BUN 7.7 Crea 47 uric acid
0.27 AST 35 ALT 29 alb 30 Ca 2.55 Mg 1.01
Choles 4.14 Trigly 1.28 HDL 0.96 LDL 2.60 FBS
6.2
FT4: 18.5
TSH 1.5
CXR
Normal fiding
ECG
Sinus tachycardia, NSSTTWC
PT/PTT
13/13/99/1/29/26.7
Cranial CT scan
CVA bleed L putamen
2D echo
EF 72%
Concentric remodelling of the left ventricle
with good wall motion and contractility and
preserved overall systolic function
Ff up official CXR
(+) crackle L lower, decreased
BS R
Refer to rehab c/o Dr.Ignacio if
ok with neuro once BP stable
Dr. Anlacan OOT(528-30),
Dr.Astejada to cover
For:
FOBT
FF.up:
Repeat CBC
CENICU 12
CN 4017812
MATIAS, CRISTETA
65/F
3/7: Michelle
Dr. Tordesillas/ Dr. Pasco
(neuro)/Dr.Dimacali(renal)/ Reyes
(CVS)/Dr.Satiaguel (pulmo)
Admitting Impresion:
Encephalopathy pob. 1. Metabolic 2.
Septic
CAP, MR
r/o CVD
HTN
DM
Neuro:
Encephalopathy 1. Metabolic
AKI prob sec to poor intake on top of
chronic disease secondary to
hypertensive/ diabetic nephropathy
CVS: Encephalopathy resolving proib
metabolic
AKI on top of CKI 2 HPN
HPN
DM 2
BANIAE
Anemia, multifactorial 1 nutritional, 2
chronic disease
t/c atrophy of disuse
Pulmo:
ARF sec to CAP with aspiration
component
BANIAE cannot rule out PulmoEmbo
AKI on top of CKD sec to HTN/DM
nephropathy
HTN
DM
CC; decrease sensorium
Patient known hypertensive,
diabetic, and asthmatic
HPI: sudden onset of decrease
sensorium, described as difficulty
to ariuse and no verbal output.
Phone order fro Family friend MD –
hook to LR.
3 hrs PTA noted CBG to be low
63. Advised to shift IVF to D5W,
however no improvement, hence
consult.
IVF:
Diet: OF via NGT 1600 kcal in 6 equal feedingsAntibiotics:
Meropenem 1g IV q 12h
Piptazo 2.25g IV q 8H (D2)
Azithromycin 500mg (D3)
Meds:
Salb neb q6
Insulin Aspart 14 u PB, 8u PL 8u PD - HOLD
Imdur 30mg
Clopidogrel 75mg
Vastarel 35 mg
Amlodipine 5mg
Paracetamol 500mg/tab q6 RTC
Salbutamol neb q 4h
Citicholine 1g q12
NAC
ASA 80mg OD
Enoxaparin 0.4cc SC OD
Omeprazole ??
Furosemide IV 60mg due to decreas output
CBC:
3/30: 98/0.333/9.33/0.89/0.07/372
3/24: 100/0.328/12.8/0.89/0.08/204
3/10: 99/0.332/15.92/274
3/8: 99/0.330/9.85/0.86/0.09/290
Blood Chem:
3/19: K 3.0
3/16 Crea 310, K 4.2
3/14 Mg 1.13, K 7.9- 5.6
3/13: Na 140 K 2.9 Cl 112 Crea 299 Ca 1.85
Mg ).59
3/10: Na 143 K 5.4 Cl 116 Crea 283 alb 24 Ca
(2.36) Mg ).83
3/9: Chole 4.34 Trig 0.93 HDL 1.65 LDL 2.27
FBS 4.2 Crea 257 K 2.8 CO2 28,7 Hba1c 8.5
3/8: Na 149,K 3.8 Cl 112 BUN 21.3 Crea 309
AST 35 ALT 19 alb 28 Ca 2.32 Mg 1.05
Urine chem.
3/23 Na 22.09/K 18.88/Cl 26.71/crea
133.48/TP 536/TV470
HBA1c: 8.5
Discontinued
Inotropes: Dopamine 2 amps in 250 D5W x 22cc/hr
Unasyn 750mg IV q8 (D1+2)
MgSO4 3g in 250 D5W x 24 hrs
d/c Pip tazo D10
Dobutamine 2 amps in 250 D5W x 18 cc/hr – OFF
Norepinephrine 2 amps in 250 D5W x 16 cc/hr - OFF
Oral KCl 20cc TID x 4doses
ABG:
3/30 b: 7.513/32.2/57.2/26.2/4.2/92.2
3/30 a: 7.518/35.8/186.4/29.4/6.9/99.7
7.402/34.5/155.2/21.6/99.3
PT:
13.30/12.6/112/0.94
PTT:
29/23.5
CXR
Provisional – pneumonia, R, bilat pleural
effusion L>R, cannot rule out congestive
changes
Chest UTZ:
Right: Hypoechoic ICJ 290ml
Left Hypoechoic area ICJ 140ml
2d echo
Provisional: 37% EF, wth moderate wall
hypokinesia
Re-intubated (desat 88-89%,
dyspnea tachypnea)
s/p BT 1u PRBC?
s/p intubation
s/p arrest 11 minutes
(+) watery stools, total of 10x
since feeding was resumed,
non-bloody, no fever
Latest VS 110/80 80 20
afebrile
CBG while OFF feeding 180/
113/115
DNR status
FF up:
ETA GS/CS
Repeat CBC
Sputum GS/CS
Sputum AFB
Blood CS
CBG
3/14: 104
3/13: 118/113
3/12: 67/118/87/109/
100/142/113/105
3/11: 269/240
3/10: 122
3/9: 421/340/271/135
MV: AC, IFR 50, FiO2 25%, TV
360, PEEP 5, BUR 12
REFERRALS
745
CN 4018042
SERRA, IGNACIO
40/M
Dr. Roa(pulmo)/Dr. Pasco(Neuro)Dr. Ang
CC: Dyspnea
IVF:
For home care preparation c/o Hospice
Known case CVD with pneumonia unable to
wean.
S/p PEG and Tracheostomy last February
and was discharged
Diet: OF
Including mech vent
RE addmited last March due to dyspnea and
increase productive
CVD bleead Basal Ganglia/Pons and
Midbrain
Pneumonia resolved
s/p PEG
s/P Tracheostomy
Unresponsive, stable
Meds:
Acetazolomide 250mg/tab
Methimazole
Nac 60mg/tab
Esomeprazole 40mg/tab
Lactulose 30cc OD ODHS
Levetiracetam 5mil BID per peg
Amlodipine 10mg/tab per peg
Salbutamol + Ip Bromide
For home
CO-MANAGEMENT
568-2
CN
ROLA, ELIEZER
68/M
Dr. Ignacio/Dr. Bausa
Pancreatic CA w/ intestinal mets
s/p EGD
CC: UGIB
HPI: Known case of Pancretic CA with
intestinal mets
s/p surgery, s/p Chemotherapy
3 months PTA, patient had melena and
hematemesis which was followed by gen
body weakness
Meds:
Morphine 10mg ½ tab q 6 RTC
If tab is not available give Morphone 3mgIV
q4
Metoclopramide 1omg/tab
Omeprazole 40mg/IV q8-> 40 mg PO BID
HNBB 10mg IV q8
Tramadol 50mg/IV
Tranexamic acid 1amp TID PRN
Norspan 5mg patch q 7 days
Levofloxacin 750mg tab OD
Senna Forete 374mg tab OD HS
CBC
95/0.241/7.89/445
MGH once settled
PF 4.6K
Blood Chem
BUN 108/Crea 104/AST 27/ALT 10/ALb
29/Ca 2.17/ Na 132/ K 4.6
(+)abdominal pain and distention, black
tinged vomitus, nausea
EGD result: infiltrating mass at the junction
of D1/D2, no active bleeding or ulcers
s/p BT1 unit PRBC
For BT 1u PRBC
CBG 215, 186
For:
CXR
Sputum gs/cs
CI
CI 27 B49
CN 3987619
REYES, REMEDIOS
50F
3/14: Sianghio
Breast CA
Pathologic fracture 2 BRCA
metsprobsubtrochantrealacrea
Pleural effusion, left
606-2
CI 28 B39
3921342
Known case breast CA with pulmo mets(?)
s/p 8 cycle chemo
s/p CTT
IVF: heplock
DOI: 2/17/14
TOI: 10:30AM
MOI: fall
POI: valenzuela city
Antibiotcs:
Meropenem 1 grm TIV q 8 D5
Patient had a dental procedure and was
about to be transferred to a wheelchair
when a cracking sound was heard and
patient was noted to have deformity and
pain on right thigh
CC: Abdominal pain, epigastric
CC: Weakness
Diet: OF feeding at 1125 kcal
Meds:
Appebon tab OD
Doxophylline 200mg tab BID
Morphine Silfate 2 tab q 4 RTC, I tab for BTP
Senna 2 tab ODHS
Dulcolax supp if no BM for 3 days
Furosemide +Kcl tab OD for 7 days
DISCHARGED
Metoclopromide
10mg tab q 8 prn
HNBB 1omg TIV q 6 PRN
Calmoseptine
ointment
IVF: PNSS 1l
x 12h BID
Salmeterol + Fluticasone 200 ,cg I puff BID
Salbu + ipra neb q 4 prn
Gaviscon q8 PRN
KCl 10% 30cc 1 of 4
IVF: PNSS 1L 8 hours for 1 cycle
PNSS 1L x12 hours
HPI:
RONQUILLO, MILAGROS
CERVANTES
61/F
3/6 Shianghio
Breast CA stage IV S/p Chemo 6 cycles
Known Case of Breast CA stage IV with
bleeding, S/P Chemo 6 cycles, HPN stage,
Tyoe 2 DM
1 month Patient had general body weakness
and pale looking. CBC was done and
revealed a 85 hemoglobin
Few hours PTA, patient fainted after walking
at the stair in PGh.
Hold Enalapril 10mg/tab OD
Gliclazide 80mg/tab
Simvastatin 10mg ODHS
Tamoxifen 20mg/OD
Vitamin D + Caco3 tab
Bisacodyl ODHS
Metformin 500mg/tab BID
Ferrous Sulfate tab
Gabapenin 300mg/tab BID
Tranexamic acid 500mg/tab
Tramadol 50mg q8
MoSO4 10mg a tab q 4 RTC
CBC:
3/18: 125/0.380/4.82/0.76/0.09/328
3/6: 108/0.340/4.06/0.83/0.09/413
Blood chem:
3/17: Na 125 K 3.1 Cl 95 Crea 23 AST 44 ALT
19 alb 23 Ca 1.82 TP: 60 LDH 1342
Clear CTT output
DNR/DNI status
No chemo
No radio
Refer to GS, still awaiting entry
Refer for Dietary for upbuilding
Blood CS:
NG2D
PT/PTT:
2/21: 13.3/12.4/116/0/92 29/25.8
ECG: RSR, NA, LAE, NSSTTWC
CBC
3/22
119/0.371/6.31/0.84/0.11/0.04/0.01/381
3/9: 113, 0.354, 6.11, 0.63, 0.26
3/5: 71/0.237/6.61/0.55/0.38/599
(-) bloody discharge per CTT
s/p BT 2 u PRBC
For:
U/A
Post correction Mg, K, Cl
Chest UTZ s/p Open Chole (3/28)
s/p 6/10 RT
Complains of dizziness and stress, hip pain
4/10 relieved by analgesic
With BTP 1x and unable to proceed with RT
PT/PTT
3/5: 13.3/12.6/112/0.94 29/28.5
Bloodchem:
3/10: BUN 3.3, Crea 70
3/6:Chole 3.02 TG 0.78 HDL 1.13 LDL 1.54
FBS 5.5 HBa1c: 5.0
Na 143 K 2.8 Cl 105 cra 92 AST 40 ALT 14 alb
34 Ca 2.39
ECG:
RSR, NA, NSSTTWCs
Urinalysis
3/6: 5.5/1.020/neg/neg/rbc 0. Wbc 205
CT scan provisional
No mass, increase hemidiagram left
Positive consolidation left
Follow-up
Chest CT scan with Contrast
For rehab referral for possible bracing
Bone scan:
3/17: multiple bone metastasis with
progression since 4/29/13
Wound GS
Gram neg bacilli 3-5
Gram + cocci 2-4
E. Coli mod-heavy growth
P. Aeruginosa
S. Ceftazidime Gentamicin
CN
MANUTA, BUENA
60/f
3/25 ALEX
Dr. Tordesillas/Dr. De Vera(GS3)/Dr.
Dans (CVS)
HPI: History of epigastric pain last 2012, relieved with
unknown meds.
Diet: DAT
Few hours PTA, patient had epigastric pain, burning
with reflux. Seen at ambu and given Ranitidine and
Metoclopramide. Pain decrease but still persisted
hence admission
Meds
Omeprazole 40mg/IV OD D/c
HNBB 10mg/IV
AlMg OH 2 sachet 3x a day
Atorvastatin 10mg tab ODHS
Cefuroxime 750mg IV q8 – d/c
Simvastatin 40 mg ODHS (suggested by
CVS)
Arcoxia 120mg/tab once a day
CC: hip pain
HPI:
15 hrs PTA – (+) fall from the stairs allegedly falling on
her buttocks and not hitting the head.
Consulted at FMAB xray done showed (-) for fracture.
IVF: heplock
DAT
CBC
126/0.401/201/9.24
Meds:
Tramadol 50mg IV q12 shift 50mg/tab TID
Amlodipine 5mg tab OD
Colchicine 500mg tab OD
Blood Chem
Na 137/k 2.6/Cl 1000/Bun 2.3/Crea 73/Ca 2.13
GERD
Calculous cholecystitis
416-4
CN
ARRIESGADO,
PREMITIVA
HA-UTS: fatty liver changes, calculous cholecystitis
CXR: provisional suboptimal inspiration, intercurrent
pneumonia not ruled out
Had back pain yesterday from
previous history of Slip Disc
For possible D/c today once with
no symptoms
Blood Chem: Na 136, K 3.8, Cl 103, Chole 245, TG 83,
HDL 74, LDL 155, FBS 126 BUN 2.9 crea 72 BUA 0.33
AST 37 ALT 28 alb 39 Ca 2.38 Mg 0.87
HBA1c 5.7
Urinalysis:
Yellow/clear/6.0/1.009/RBC 35/WBC 9
(+) hip pain decrease 3/10
For possible discharged
83/F
No pain
For:
Uric acid, Lipd profile
3/28: Michelle
Dr. Limpoco/Dr. Tee (Rheuma)
Osteoarthritis
HTN St II, controlled
MORTALITY