PHILIPPINE GENERAL HOSPITAL
SUMMARY
Old Patient(s)
New Patient(s)
Discharge(s)
Mortalities
OR
TOS/Sign Out
Transfer to Wards
HAA/Absconded
Home Per Request
Transfer to HOC
TOTAL NSS- ER PX
Department of Neurosciences, Section of Neurosurgery
University of the Philippines-Manila
The National University Hospital
Taft Avenue, Ermita, Manila
“PHIC Accredited Health Care Provider”
Daily Patient Census
as of April 15, 2010 7:00 AM
ROD: Dr. Nathalie Lee
IOD: Int. Vinna N. Crisostomo
6
11
1
0
2
0
1
0
0
0
15
NEW ADMISSIONS (2)/REFERRALS (9)
Location/1o SVC
Patient
Present Working Impression
ACU (OU)/
NSS
HERRAS, Medita
50/F
CN 3526577
Admitted: 04/14/10
T4 Meningioma
s/p T4 Laminectomy, escision of
tumor (Pua, 3/2/10)
NSS ICU/
NSS
ASUNCION, Aileen
51/F
CN 3553873
SAH Grade I prob sec to ruptured
ACOM aneurysm
PER/
Pedia
FERNANDEZ, RIAN
2/M
CN 3553791
Referred: 4/14/10
MI sec to VC
PER/
Pedia
PEREZ, Jyrus
2mos/M
CN 3558830
Admitted : 04/14/10
Lumbosacral mass
t/c Meningocoele vs
myelomeningocoele
PER/
Pedia
INOY, Kurt
2/M
CN 3340808
Admitted : 04/14/10
Congenital Hydrocephalus
Bilateral subdural effusion
s/p VPS insertion (10/29/10)
s/p Bilateral burr hole, evacuation
of hematoma (3/15/10)
Brain abscess
Pertinent Laboratory Findings
Opos
Hgb 124/ Hct 0.367/ WBC 9.76 (N 0.574 L 0.360)/
Plt 480
PT 13.5/10.7/>1.01/1.03
PTT 37.7/57.6
BUN 2.50 Crea 69 Na 140 K 4.1 Cl 104
Plan
DAT with SAP
IVF: PNSS x 8h
Dx: CBC, BT, Na, K, Cl, BUN, Crea, PT/PTT, CXR
Wound discharge GS/CS
Refer to IDS
Admitted: NSS ICU
CT: (-) hematoma, (-) fx, (-) MLS, intact cisterns, (-)
hydrocephalus
IVF: D50.3NaCl @ 67cc/hr
Tx: Cefuroxime
Oxacillin
Paracetamol 150mg IV q4 RTC
Omeprazole 5 mg IV q12
NPO, Hgt q12
Maintain OGT open to drain
Monitor OGT output q4 and replace with pLR q4
Strict asepsis and handwashing
O2 support 5lpm via FM
Dx : PT/PTT, CBC, UA, Na, K, Cl, BUN, Crea,
Babygram APL, Lumbosacral APL
Tx: Defer
IVF: heplock
Regular diet for age
VSq4
Dx: PT/PTT, CBC, Wound discharge GS/CS,
Cranial CT plain and with contrast, BUN Crea
Tx: PenG (300,000 u/kg/d) 1M ‘U’ IV q6
Chloramphenicol (75mg/kg/d) 265mg IV q6
Regular diet for age
Heplock
Daily wound care with betadine
Monitor vsq2 with NVS
PER/
Pedia
VAQUI, Myesha
4mo/ F
CN 3558319
Admitted : 04/14/10
Post-meningitic hydrocephalus
PER/
Pedia
TAGURA, BB Girl
NB/F
CN 3553822
Admitted: 04/14/10
t/c Encephalocoele
ACU/
Trauma
ACU (14)/
Trauma
ACU (12)/
Trauma
FAGUT, Timothy
11/M
Referred: 04/14/10
SOSOSCO, Roger
31/M
CN 3553812
Date referred: 4/15/10
BALDO, Warren
26/M
CN 3553834
Date referred: 4/15/10
MI sec to Fall
MI sec VC
NIEBRES, Janice
21/M
CN 3558322
Date referred: 4/15/10
Cerebellar abscess, right
CSOM, right
Location/1o SVC
Patient
Present Working Impression
AGAPAY, Romnick
22/M
CN 3553736
Admitted: 04/13/10
OR
CT (19hrs PI): (-) hematoma, (+)TSAH, (-) fx, (-)MLS, (-)
HCP, intact cisterns
MI sec VC
ACU (15)/
Neuro
ACU (SC)/
NSS
DX : CBC, BUN, Crea, Na, K, Cl, Ca, PT/PTT, CXR
Tx : Acetazolamide (20mkd) 50 mg IV q8
Breastfeed as tolerated
IVF : Heplock
VSq2
Strict asepsis and HW
DX : BT , CBC, Na, K, Cl, Ca, Chromosomal
analysis, NB screening, Babygram APL, CT scan
plain with contrast
Tx : Ampicillin(100mkd) 135 mg IV q12
Amikacin (15mkd) 40 mg IV OD
Phenobarbital (5mkd) 5mg IV q8
OGT feeding to 30cc EBM
IVF : D10IMB 270 @ 11cc/hr
IC Bleed w/ IV extension prob 2o
to ruptured AVM
CT (4/10): (+) well-defined slightly hypodense focus
with an enhancing rim in the right cerebellar
hemisphere aprrox 2.9 x 2.7 cm
BACKLOGS (6)
Pertinent Laboratory Findings
BT A+
Hgb 130 Hct 0.378 WBC 13.9 (N 0.818, L 0.098)
Plt 127
PT 12.1/12.0/0.92/1.15
PTT 35.2/36.3
BUN 2.23 Crea 64 Na 138 K 4.0 Cl 99
Cranial CT scan plain (04/13/10):
(+) 5x3x4 30cc ICH L occipital area w/ IV extension,
(+) 0.3 cm MLS, (+) effaced cisterns/sulci
ACU (SC)/
TRAUMA
MORALES, Luisito
27/M
MI 2o to VC
1. Abrasion – face, back, R flank,
Cranial CT scan plain (04/13/10):
(+) 3x5x1.5 11.25 cc contusion hematoma L frontal,
IVF: 1L PNSS x 12h
DAT with SAP
Tx: Ceftriaxone 2gIV q12
Metronidazole 500mg/tab q6
Dexamethasone 4mg Ivq6
Mannitol 100cc IV q6
Lactulose 30cc OD at HS
Omeprazole 40 mg/tab OD
NVSq4
Plan
NPO
IVF: pNSS 1L x 8h
Maintain FC
Refer to Neuro, IR
Dx:
Ff-up official results of BT, PT/PTT, Blood chem
FF-up U/A, CXR, ECG
Tx:
Mannitol 100 cc IV q4
Citicholine 1 g/tab 1 tab q12
Ketorolac 30 mg IV q8 prn for HA
Maintain FC
Refer to Trauma, ORL
Referred: 04/13/10
ACU (IFO NS)/
OU
OU (17)/
NSS
OU (11)/
NSS
OU (8)/
TRAUMA
PAALISBO, JOEL
30/M
CN 3553448
VALENTINO, Felomino
49/M
CN 3556093
Admitted: 04/02/10
CADIZ, Flora
31/F
CN 3550638
Admitted: 04/06/10
ANIT, P-Jay
7/M
CN 3553431
Referred: 04/10/10
B hands
2. t/c Intracranial Injury
Compound fracture frontal bone
Pneumocephalus
Brain tumor
Left FP Mass
t/c Low Grade Astrocytoma
MI 2o to Fall
Highly considering an epidural
bleed of the cervical SC vs SC
abscess
(+) 0.5 cm MLS, (-) HCP, (+) effaced basal cistern
BT B+
Hgb 168 Hct 0.469 WBC 14.6 (N 0.780, L 0. 138)
Plt 296
PT 12.3/ 10.8/ >1.0/ 1.04
PTT 34.9/ 28.8
Cranial CT scan plain with BW (04/10/10): (+)
compound fx frontal bone, (+) pneumocephalus, (+)
hematoma, (-) MLS, intact cisterns
Hgb 103 Hct 0.309 WBC 7.10 (N 0.652, L 0.276) Plt
348
PT 11.0/12.2/0.89/1.17
PTT 32.6/37.3
Gluc 11.8 BUN 6.79 Crea 117 Na 127 K 4.1 Cl 88
(4/3)BUN 5.77 Crea 124 K 4.0 Cl 90 Na 127
(4/6)BUN 2.46 Crea 108 Na 126 K 4.0 Cl 90
(4/8)FT4 8.4 TSH 0.8 Cortisol 25 Prolactin 3041.9
(4/10)Na 126 K 4.1
(4/12)Serum: Na 119 K 4.0 Cl 85, Urine: Na 238 K
166 Cl 213
BT O+
Hgb 128 Hct 0.373 WBC 11.2 (N 0.774, L 0.156) Plt
396
PT 12.1/12.5/0.84/1.20
PTT 35.1/42.0
Glu 7.35 BUN 2.09 Crea 79 Na 138 K 3.7 Cl 100
U/A: yellow sl hazy SG 1.005 pH 8.5 CHO (-) CHON
(-) RBC (-)
Cranial CT scan plain (06/2009):
Left FP mass 2.5x4x4.5 cm mixed heterogenous, (+)
MLS 1 cm, compressed basal cistern
BT B+
Hgb 108 Hct 0.317 WBC 9.0 (N 0.824, L 0. 147) Plt
394
BUN 2.39 Crea 37 Na 135 K 3.8 Cl 101 Ca 2.23 Mg
0.81 GLu 7.66
Cranial CT scan plain w/ BW (04/10/10):
(-) Hemorrhage, (-) fracture, (-) HCP, intact cisterns
MRI:
No spinal instability
Cervical APL w/ OM (04/10/10):
(-) Fracture, (-) listhesis
Dx:
For repeat cranial CT scan plain tonight
Tx:
Mannitol 150 mg IV q4
Tramadol 50 mg IV q8
Soft diet with SAP
IVF: pNSS 1L x 10h
Pen G 4MU IV q4
Chloramphenicol 1 g IV q6
Tramadol 50 mg IV q8
Continue IV antibiotics to complete 7 days
ORL:
For transphenoidal punch biopsy of sphenoid mass
For PTA-ST once more stable
Ophtha:
For Perimetry once w/ funds
NSS:
Requesting for TOS to ORL
Dx:
Ideally for Cranial MRI w/ GAD if w/ funds
Tx:
NaCl tab TID
Tramadol 50 mg/tab 1 tab TID
Arcoxia 90 mg/tab 1 tab BID
IVF: D5NR 1L X 8h
Remove FC
Dx:
Ideally for Cranial MRI if w/ funds
Tx:
Mannitol 75 cc IV q8
Dexamethasone 4 mg/tab 1 tab q12
Omeprazole 40 mg/tab 1 tab OD
Lactulose 30 cc OD HS
Tx:
No emergent NSS intervention
Citicholine 500 mg IV q12
Location/1o SVC
ACU/
TRAUMA
DISCHARGE (1)/SIGN-OUT (0)/ TRANS-OUT (0)/ HOME AGAINST ADVICE (0)/ MORTALITY (0) / OR (2)
Present Working Impression
Pertinent Laboratory Findings
BT O+
Hgb 117 Hct 0.352 WBC 19.6 (N 0.775, L 0.138)
Plt 312
PT 12.1/11.0/>1.0/1.06
DE MESA, Angelica
PTT 35.2/29.8
Nina
BUN 4.26 Crea 63 Na 139 K 4.0 Cl 101
9/F
EDH
OR
CN 3553755
Cranial CT scan plain (04/13/10 2 hrs PI):
Referred: 04/13/10
R parietal EDH 12cc (hyperacute), (+) mimimal MLS,
intact cisterns, (+) linear fx R temporoparietal area
Patient
Repeat Cranial CT scan plain (04/13/10):
ACU (7A)/
TRAUMA
OPENA, Malvin
34/M
Referred
MGH
BT A+
Hgb 139 Hct 0.439 WBC 14.3 (N 0.38, L 0.46) Plt
450
OU (22)/
PEDIA
SATUR, Johnsen
11/M
CN 3478758
Post-meningitic Vetriculomegaly
PT 12.1/10.8/>1.01/1.040
PTT 36.4/33.8
Na 138 K 4.1 Ca 2.49 Cl 102 ALT 50 AST 22
U/A: yellow clear SG 1.010 pH 6.5 CHO (-) CHON (-)
RBC (-) WBC 1 EC 3
Cranial MRI:
Severe Ventriculomegaly of lateral, 3rd and 4th
ventricles, cisterns enlarged, good sulci-gyri interface,
(-) mass/hematoma
OR
Plan