DEPARTMENT OF INTERNAL MEDICINE

DAILY CENSUS
SEPTEMBER 5-6, 2023
COC DR. ALEJANDRO

ER ROD DR. LIMEN/DR. LIBRE

WARD DR. PINSOY/DR. GOKOTANO

ICU ROD DR. KARLOS/DR. WEE

PGI SARAYAN/IRENEA/ARARAL/INSULAR/PIQUIT/FABIAÑA

CLERKS INAMARGA/HUSAIN/GIO/LINOGAO/YU/LANCARA

DISPOSITION
NUMBER OF VACANCIES PER AREA
ADMISSIONS 9
UNIT VACANT RIGHT LEFT
ER REFERRALS 1
GEN MED 1 P: 1 1-7 48-52
NEW WARD REFERRALS 2 MW (50): 1 1`
CW (51): 2
HOLDING AREA/ ER ISOLATION 0
FW (52): 0
TRANSFERRED TO ICU 0 GEN MED 2 3 8-15 38– 47

TRANSFERRED FROM ICU TO WARD 0 GEN MED 3 17-27 28-37

TRANSFERRED TO OTHER HOSPITAL 0 FAMMED P2 217-220 221-225

SP2
DISCHARGED 10 SURGICAL WING 201-208 209-216
MORTALITY 0 EXEC WING 1 231-233 226-230
OB WING 234-248
DISTRIBUTION OF IM IN-PATIENT
DR/LR
GEN MED 1 6
ICU .
GEN MED 2 12
ICU EXTENSION
GEN MED 3 14 PEDIA WING 53-60 61-63

SURGERY WING 12

EXECUTIVE WING 7

FAMMED WING 7

FEMALE SERVICE WARD 2

PICU 0

OB WING 0

DR/LR 0
 ICU 2

ICU EXTENSION 0

PEDIA WING 0

TOTAL IM IN-PATIENTS

ADMISSIONS: 9

DATE RM PATIENT’S AGE/ CHIEF PHYSICIAN REASON FOR REMARKS SERVICES

ADMITTED NAME SEX COMPLAINT ADMITTING DIAGNOSIS REFERRAL

09/05/23 22 DIONGSON, 86/M DECREASED Acute CVA Infarct prob posterior Cerebral artery Dr. Licayan (PC) Dr. A PNSS 1L @ 100 cc/hr
AMIE SENSORIUM NIHSS - 8 HCVD Abou zaki (CM) D Soft diet with strict aspiration precaution
M VS q4, NVS 4, I and O q shift
I
U (70
M
1. Atorvastatin 80 mg 1 tab OD HS
2. Citicoline 1 gm IV q 12
3.CARVEDILOL 6.25MG TAB BID
4.OMEPRAZOLE 40MG TAB 1 TAB OD
SENOKOT FORTE 1 TAB OD HS

L
09/05
CRANIAL CT SCAN PLAIN
IMPRESSION:
ACUTE NON-HEMORRHAGIC INFARCT, RIGHT OCCIPITAL LOBE
CHRONICE INFARCT, LEFT PARIETAL LOBE
CEREBRAL AND CEREBELLAR ATROPHY
BILATERAL INTERNAL CAROTID AND VERTEBRAL
ATHEROSCLEROSIS
CHRONIC MAXILLARY SINUSITIS,LEFT

CXR
IMPRESSION:
PULMONARY CONGESTION
LEFT VENTRICULAR CARDIOMEGALY
ATHEROSCLEROTIC AORTA
THORACIC SPONDYLOSIS

CBC
WBC 12.0
RBC 5.5
HGB 16.5
HCT0.49
PLT 230
N 0.84
L 0.09
M 0.04
E 0.02
B 0.01

MG 0.65
CA 1.12
 CREA 101
K 3.08
NA 142.7
FT4 0.98
TSH
SUA 535
HBA1C 5.5

U
09/05
Conferred with Dr. Licayan
Start Amiodarone 200 mg 1 tab TID
Refer to Dr. Abuo zakit for co-mgt
09/05/23 RM19 LLOREN, JOEL 54/M RUQ PAIN CHOLEDOCHOLITHIASIS DR. VELASCO (PC) A D5NSS 1L AT 100CC/HR
GM3 D LOW FAT DIET
M VS Q4HRS; I/O QSHIFT
I
U CPK
M
1. VITAMIN K 10MG IN 50ML NSS IN SOLUSET TO RUN IN 30 MINS
Q8HRS
2. AMPICILLIN + SULBACTAM (AMSULVEX 1.5MG IVTT Q8HRS (TO
START AT ER)
3. DOLCET TABLET, 1 TABLET EVERY 8HRS AS NEEDED FOR PAIN
4. PANTOVEX 40MG IVTT AT 6AM ON THE DAY PRIOR TO ERCP

L
09/05
WBC 6.9
RBC 4.0
HGB 12.4
HCT 0.38
PLT CT 257
N 0.79
L 0.15
M 0.04

CXRAY
NEGATIVE CHEST XRAY

PROTIME

U
09/05
09/05/23 30 Revilla, 74/M Edema Pulmonary congestion prob secondary to Heart DR. OMBAO (HC) A PNSS @ KVO
Narciso failure D low salt Low fat, DM
Chronic Venous Insufficiency MVS q4, I/O q shift
Hypertensive Cardiovascular Disease, Heart Failure I
FC III U
Anemias prob sec to CKD sec to DKD/ HKD M
T2 DM 1. Albumin 20% + 40 mg Furosemide x 4 hours q 12 hours
S/P CVA with left sided residual weakness (congestion precaution)
2. Mg so4 2 gm + 20 cc NSS slow iv q8 x 2 doses
3. Trimag 1 tab TID
4. RI Sliding scale
CBG RI SQ
180-220 4 units
221-260 6 units
 261-300 8 units
>300 10 units

L
09/05
CBG 130 mg/dl
ECG Sinus tachycardia, RBBB incomplete

WBC 9.7
Hgb 8.8
Hct 0.26
Plt 244
N 0.71
L 0.20
M 0.08

Albumin 18

Creatinine 181 (egfr 33)

SUA 491

Na+ 137.0
K+ 3.92
Ca++ 1.17
Mg+ 0.57

U
09/05
09/05/23 3 CARTAJENA, 74/M DYSPNEA Pleural Effusion Left prob parapneumonic DR. B. RAMOS (PC) A PNSS @ KVO
SEGUNDINO CAP - MR
End Stage Renal Disease Secondary to HKD D low salt Low fat renal
HCVD, CAD, LVH
M VS q4, I/O q shift

1. Sodium Bicarbonate 650 mg 1 tab TID

2. Amlodipine 10 mg 1 tab OD

3. Losartan 50 mg 1 tan OD

4. Trimetazidine 35 mg 1 tab BID

5. Aspirin 80 mg 1 tab OD

6. Clopidogrel 75 mg 1 tab OD

7. Atorvastatin 40 mg 1 tab OD
8. Ferrous Sulfate + Folic Acid 1 tab BID

9. Calcium Carbonate 500 mg 1 tab BID

10. Erythropoeitin 4000 units SC 2x per week

09/05

CBC

Wbc 9.8

Rbc 2.9 (L)

Hgb 8.2 (L)

Hct 0.27 (L)

Plt 280

N 0.74 (H)

M 0.07

L 0.17 (L)

E 0.01

CXRAY

MODERATE PLEURAL EFFUSION, LEFT

USD CHEST: Bilateral pleural effusion with passive atelectasis of

left lower lobe

incidental finding of minimal ascites

ECG

CXR, RAT, RT PCR

Na+, K+, Mg, Ca++

Creatinine BUN

SGPT, Phosphorous
 Pro BNP

UTZ of Chest

Blood cs x 2 sites

Sputum GSCS

09/05

09/05/23 219-C HINGGOS, 64/M NON HEALING Non healing wound, left anterior shin DR. R. TAN (PC) A PNSS 1L@ 100 CC/HR
ANECITA WOUND, LEFT Type II diabetes mellitus
ANTER D diabetic diet; allergic to chicken and seafood

M VS q4; I&O qshift

I Piptaz D0

U cpk

1. 1. Piperacillin + Tazobactam 4.5 gm IVTT q6

2. Metformin 500 mg/tab OD

09/05

WBC

RBC

HGB

HCT

PLT CT

M
 Blood culture 2 sites

Wound gscs

Na

CBG

UA

AV duplex scan

09/05

09/05/23 39 BADA, 82/M DIFFICULTY PULMONARY MASS, RIGHT T/C MALIGNANT DR. GALICIA (PC) A: PNSS 1L AT 60CC/HR
JUANITO OF HYPERTENSION STAGE 2
BREATHING D LOW FAT LOW SALT DIET

M VS Q4 I AND Q SHIFT

1. LOSARTAN 50 MG 1 TAB OD

09/05

CBC

WBC 13.1

RBC 4.7

HGB 12.8

HCT 0.40

PLT 316
 N 0.73

L 0.17

M 0.07

E 0.02

B 0.01

K 4.49

NA 139.9

CREA 104

CA 1.26

MG 0.72

RAT NEGATIVE

09/05

09/05/23 226 BULLANDAY, 48/F DYSURIA PARTIAL INTESTINAL OBSTRUCTION SECONDARY TO DR. OTERO A D5LR 1L AT 100C/HR
CELSTINA RECTAL CARCINOMA R/O URINARY BLADDER
INFILTRATES HYPERTENSION STAGE 2 D LOW RESIDUE SOFT DIET

M VS Q4 I AND Q SHIFT

1. SULTAMIICILLIN 1.5 G IV Q6

2. BISOPROLOL 5MG 1 TAB OD

3. BOWEL PREP

a. DULCOLAX 5 MG 2 TABS BEDTIME

b. DULCOCLAX 10G SUPPOSITORY AT 5AM

09/06/23 34 MALABON, 64/M BACK PAIN LUMBAR SPRAIN R/O FRACTURE DR. J. RAMOS (PC) A: PNSS 1L AT 50CC/HR IM
PEDRO PULMONARY MASS, RIGHT
D: DAT
 M: VS Q4; I&O QSHIFT

I:

U: (49 KGS)

M:

1. TRAMADOL 50MG IV NOW THEN Q8 FOR SEVERE PAIN

2. NORGESIC FORTE 1 TAB Q8

L:

09/05

WBC 12.4

RBC 5.0

HGB 14.4

HCT 0.45

PLT 268

N 0.75

L 0.12

E 0.06

M 0.05

B 0.01

CREA 81

U:

09/05

9/05.23 ICU CATIPAY, 39.M BODY ARF TYPE 2 SECONDARY TO OSAHS DR. D BERNARDO A IVF PNSS 1L FD 500CC NOW THEN REGULATEAT 180 CC/HR IM
RICHARD MALAISE HYPERTENSION STAGE 2 (PC)
AKI ON TOP OF POSSIBLE CKD SEC TO HPNNS DR. MAGALLANES D START ENSURE 1800 KCAL / DAY IN 6 DIVIDED FEEDINGS
GOUTY ARTHRITIS NOT IN FLARE (CM)
M VS Q HOURLY AND I AND O Q HOURLY

U
 M

1. PIPERACILLIN+TAZOBACTAM 4.5 GRAMS LD (GIVEN AT MALTA)

THEN 2.25 GRAMS IV Q 6

2. AMLODIPINE+VALSARTAN+HCTZ 5/160/25 MG TAB OD

3. ALLOPURINOL 100 MG TAB OD

ER REFERRALS: 1

DATE RM PATIENT’S AGE/ CHIEF PHYSICIAN REASON FOR REMARKS SERVICES

ADMITTED NAME SEX COMPLAINT ADMITTING DIAGNOSIS REFERRAL

09/05/23 202-1 GABIJAN, 54/F RUQ PAIN T/C MIRIZZI SYNDROME VS CHOLEDOCHOLELITHIASIS DR. PURACAN (PC) A PLR 1L @ 115 CC/HR SURG/IM
LORNA
NOT IN CHOLANGITIS DR. LACUNA (CP) D LSLF, NPO BY MIDNIGHT

M VSQ4, I&O QS

U CPK (83 KG)

1. AMPI-SUL 1.5G IVTT 1HR PTOR

2. PANTOLEV 40MG IVTT ONCE ON NPO

L 9/5

12L ECG- SINUS BRADYCARDIA

WBC 7.0

RBC 4.7

HGB 12.9

HCT 0.41

PLT 273
 N 0.47

L 0.45

M 0.05

NA 145.4

K 3.90

CA 1.18

MG 1.03

ALK PHOS 163

DBIL 3.2

IBIL 5.9

TBIL 9.0

PT 12.1

CONTROL 13.0

INR 1.03

%ACT 89.10

U 9/5

SCHEDULE FOR OPEN CHOLE WITH IOC POSS CBDE TOMORROW

9/6/24 AT 8AM

NEW WARD REFERRALS: 2

DATE RM PATIENT’S AGE/ CHIEF PHYSICIAN REASON FOR REMARKS SERVICES

ADMITTED NAME SEX COMPLAINT REFERRAL
ADMITTING DIAGNOSIS

09/05/23 204-6 SANDAY, 41/F EPIGASTRIC ACUTE CALCULOUS CHOLECYSTITIS DR. REGONDOLA A VENOCLYSIS SURG/IM
NELFE PAIN (PC)
HYPOKALEMIA SD: PNSS 500 CC + KCL 40 MEQS TO RUN IN 50 CC/HR
 D SIPS OF WATER

M VSQ4, I&O QS

U CPK (KG)

1. AMPI SUL 1.5GM NOW THEN 750 MG IB Q8

2. HNBB 1 AMP IV NOW THEN Q8 RTC

3. TRAMADOL 1 AMP IV Q8 PRN FOR SEVERE PAIN

L 9/5

U 9/5

FOR CREA, FBS, URINALYSIS

FOR LAPAROSCOPIC CHOLECYSTECTOMY ON 09/07/23 BY 8 AM

09/05/23 204-1 OCIONES, 60/M EPIGASTRIC CHRONIC CALCULOUS CHOLECYSTITIS DR. D. A IVR PLR AT 100 CC/HR SURG/IM
MILAGROS PAIN BUENAVENTURA
(PC) D LOW FAT DIET/DAT

DR. J. CRUZ (CM) M VSQ4, I&O QS

DR. MOSQUEDA I
(CM)
U 0.7 CPK (60 KG)
DR. M GONZAGA
(ANES) M

DR. R OMBAO (CP) 1. OMEPRAZOLE 40 MG IV OD ONCE ON NPO

2. PARACETAMOL 300 MG IV Q6 PRN FOR FEVER

3. BUSCOPAN 10 MG IV Q8 PRN

4. UNASYN 1.5 GRAMS IV THEN 75- MG IV Q8

L: 9/5

NA 143.4, K 3.16, MG 0.81, CA 1.13, ALK PO4 90

APTT 29, CTRL 31, PT 12.7, INR 1.08 CTRL 13

 DB 6.5, IB 14.2, TB 20.7

SGPT 11

U: 9/5

FOR POSSIBLE LAPAROSCOPIC CHOLECYSTECTOMY

SCHEDULE TO FOLLOW

HOLDING AREA: 0

DATE RM PATIENT’S AGE/ CHIEF PHYSICIAN REASON FOR REMARKS SERVICES

ADMITTED NAME SEX COMPLAINT REFERRAL
ADMITTING DIAGNOSIS

GEN MED I: 5

DATE RM PATIENT’S NAME AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FOR REMARKS SERVICES
ADMITTED SEX COMPLAINT REFERRAL

09/03/23 1 TABBOGA, 64/M PAIN LUNG CANCER STAGE IV WITH BONE AND LEFT CERVICAL DR. QUIAMBAO (PC) A D5NSS AT 25 CC/HR
DANIEL NODE METASTASIS
PNSS 1L @ 25 CC/HR
CHRONIC KIDNEY DISEASE SECONDARY TO URATE
NEPHROPATHY D LOW PROTEIN RENAL SOFT DIET

CHRONIC TOPHACEOUS GOUT M VS Q4, I&O QSHIFT

I PIPTAZ D1

U CPK

1. COLCHICINE 0.5 MG 1 TAB OD

2. OLANZAPINE 5MG 1 TAB OD

3. TRIMAG 1 TAB BID

4. DULCOLAX SUPP. 1 SUPP OD@HS

 5. PIPTAZ 4.5G IV Q8

6. DULCOLAX SUPP, 1 SUPP@HS

7. MORPHINE 4MG IVTT Q4

8. FENATNYL PATCH 25MCG/HR REPLACE

EVERY 72HRS

09/05

NO NEW LABS

09/05

MAINTAIN IVF @ 120 CC/HR FOR NOW

MGH PER FAMILY REQUEST

PLS INFORM PALLIATIVE SERVICE

HOME MEDS AT DISCHARGE ORDER FORM

08/24/2023 2 LAVINA, 69/F DYSPNEA 09/ 05 DR. YAP - ARANIEGO A: D5W 0.3 NACL 1L @ 10 CC/HR
PURIFICACION
DR. FLORESCA (CO- D: W/NGT 1800KCAL GLUCERNA IN6 DIVIDED FEEDINGS
MGT) (300CC); JELLY DIET TRIAL; BANANA BASED TRIAL FOR
ACUTE CVA INFARCT R MCA LUGAW; FEED WITH SAP

RHD MITRAL STENOSIS, SEVERE M: VS Q4, NVS Q4, I&O QS

HCVD, AF IN MVR - RVR I: PIP TAZO 4.5 G IV Q8

T2DM, NIR U: 1.7CPK CPK (60KG)

BA NOT AE M:

CAP-MR 1. PRADAXA 110MG/TAB, 1 TAB BID @ BS

2. METFORMIN (GLUMET XR) 500 MG 1 TAB

OD @BS

3. EMPAGLIFLOZIN + LINAGLIPTIN (GLYXAMBI)

25/5 1 TAB OD

4. VERAPAMIL (ISOPTIN) 180 MG 1 TAB BID

5. BUDESODINE + FORMOTEROL (SYMBICORT)

 1 PUFF BID GARGLE AFTER

6. DIGOXIN 0.25 MG ½ TAB OD

7. SPIRONOLACTONE (ALDACTONE) 25 MG 1
TAB OD

8. ROSUVASTATIN (ROSWIN) 10 MG 1 TAB OD

HS

9. TRIMAG 1 TAB BID

10. CITICHOLINE 1G/TAB 1 TAB Q12

11. FLAMMACERIUM CREAM ON BEDSORE BID

@ BS

PRN MEDICATIONS

1.

09/05

NO NEW LABS

U:

09/05

MGH TODAY

D/C CBG MONITORING

IF STILL IN UNTIL TOMORROW D/C IVFAND SHIFT TO

HEPLOCK

09/05/23 3 CARTAJENA, 74/M DYSPNEA Pleural Effusion Left prob parapneumonic DR. B. RAMOS (PC) A PNSS @ KVO
SEGUNDINO
CAP - MR D low salt Low fat renal

End Stage Renal Disease Secondary to HKD M VS q4, I/O q shift

HCVD, CAD, LVH I

U
M

1. Sodium Bicarbonate 650 mg 1 tab TID

2. Amlodipine 10 mg 1 tab OD

3. Losartan 50 mg 1 tab OD

4. Trimetazidine 35 mg 1 tab BID

5. Aspirin 80 mg 1 tab OD

6. Clopidogrel 75 mg 1 tab OD

7. Atorvastatin 40 mg 1 tab OD

8. Ferrous Sulfate + Folic Acid 1 tab BID

9. Calcium Carbonate 500 mg 1 tab BID

10. Erythropoeitin 4000 units SQ 2x per week

09/05

CBC

ECG

CXR, RAT, RT PCR

Na+, K+, Mg, Ca++

Creatinine BUN

SGPT, Phosphorous

Pro BNP

UTZ of Chest

Blood cs x 2 sites

Sputum GSCS

09/05
08/11/23 5 LABADO, 72/M HEMATOCHE SEPTIC SHOCK SECONDARY TO HAP, MULTIPLE LUNG AND DR. ORCASITAS (PC) A: D5NSS 1L @ KVO RATE IM/SURG
BENJAMIN ZIA CHEST MASS METASTASIS VS TUMOR RECURRENCE VS
DOUBLE PRIMARY DR. HAW (CM) D: NO FOOD RESTRICTIONS; MAY HAVE SOFT DIET
WITH SAP
DR. YBIERNAS (CM)
M: VSQ4, I&O QS, O2 2 LPM/NC PRN
DR. P
BUENAVENTURA I: MEROPENEM 1 GM IVTT Q8 D3
(TSP)
U: CPK(49 KG)
DR. J PILAPIL
(ENDOSCOPY) M:

DR. MABUNGA 1. OMEPRAZOLE 40 MG 1 TAB OD X 14 DAYS

(ANES)
2. CLUSIVOL SYRUP 10 ML OD @ BS
DR. ORCASITAS (CM)
3. LACTULOSE 20 ML AT HS @ BS
DR. AYCO (CM)
4. MORPHINE 2 MG IVTT Q4 RTC (WHILE
NPO)- HOLD

5. GABAPENTIN 100 MG 1 CAP OD

6. ZYKAST 1 TAB OD @ HS X 5 DAYS

7. NAC 600 MG TAB, 1 TAB Q12

8. MEROPENEM 1 GM IVTT Q8 (WITH AMS)

9. HNBB 20 MG IVTT Q6 (WHILE NPO)- HOLD

10. Salbutamol + Ipra 1 neb Q8

PRN MEDICATIONS

1. PARACETAMOL 500 MG 1 TAB Q4 PRN

FOR FEVER

2. MIDAZOLAM 2.5 MG IVTT PRN FOR

RESTLESSNESS AND AT OD HS PRN FOR
SLEEPLESSNESS

L:

9/5
NO NEW LABS

U: 9/5
 A> HAP

Multiple lung and chest wall mets

T/c Double Primary

Hypovolemic shock sec to Acute renal

AKI sec to infection

P-

May have progressive diet

Vs monitoring q 2

CBG monitoring q 8

Hold HNBB IVTT & morphine IVTT

Facilitate sputum GSCS

OFF-service for now

08/30/23 6 LAURENTE, 49/M LEFT- SIDED PTB-CAVITY, CLINICALLY DIAGNOSED; ACUTE CVA DR. M. ONG (PC) A PNSS 1L 100CC/HR
JERRY WEAKNESS INFARCT, RIGHT MCA
D DIABETIC
DM NEPHROPATHY
M VS Q4, I&O QSHIFT
TYPE 2 DM-IR
I MYRIN P FORTE D6

U: CPK (49KG)

1. ATORVASTATIN 80 MG 1 TAB OD @ HS

2. CITICOLINE 1G/TAB Q12-RX

3. HUMULIN 70/30 24 UNITS SQ IN AM @

REF

4. HUMULIN 70/30 8 UNITS SQ IN PM @ REF

5. ASPIRIN 80 MG 1 TAB OD POST BF

6. CALMAG 1 TAB TID-RX

7. PREGABALIN + MECOBALAMIN 1 TAB BID

8. CILOSTAZOLE 100 MG 1 TAB BID

9. TRANSMETIL 500 MG 1 TAB BID

 10. MYRIN P FORTE 3 TABS OD 1 HR PRE BF

11. GLUCERNA 1 GLASS TID @ BS

12. LIVERPRIME HD 1 TAB BID

PRN MEDICATIONS

1. RI 6 U SCALE SQ FOR HGT OF >180 MG/DL

12 MN

2. PCM 500 MG 1 TAB Q4 FOR FEVER

09/05

NO NEW LABS

09/05

MGH STILL IN

CONTINUE MEDICATION WHILE STILL IN

CONTINUE CBG WHILE STILL IN

8/26/23 RM MAGLACION, 38/F CHILLS UROSEPSIS SECONDARY TO OBSTRUCTIVE UROPATHY DR. BAD-ANG A: PLR 1L AT 40C/HE IM
7 JEAN ISABEL S/P CYSTOSCOPY, DJ STENTING INSERTION LEFT
AKI SECONDARY TO OBSTRUCTIVE UROPATHY D: DAT
BA NOT IN AE
M: VS Q4; I&0 QSHIFT

I: ERTAPENEM D7

U: CPK (66.5KG)

M:

1. ERTAPENEM 1G IV OD TO RUN FOR 30

MINUTES - D/C

2. SAMBONG FORTE 2 TABS TID X 3 MONTHS

 3. TASCIT 15MG TAB BID

4. TAMSULOSIN 400MG TAB OD HS X

3MONTHS

5. URAL SACHET TID X 3 MONTHS

PRN MEDICATIONS

1. TRAMADOL 50 MG IV 8 HOURS PRN FOR

PAIN

2. PARACETAMOL 500 MG 1 TAB Q4 FOR

FEVER

L:

09/05

NO NEW LABS

U:

09/05

CONTINUE PRESENT MANAGEMENT AND MONITORING

MGH ONCE CLEARED WITH ALL AP

FF UP AFTER 1 WEEK WITH REPEAT CBC, BUN, CREA, NA,

K, URINALYSIS
 GEN MED II: 10

DATE RM PATIENT’S NAME AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FOR REMARKS SERVICES
ADMITTED SEX COMPLAINT REFERRAL
9/04/23 9 ADRALES, 71/M DYSPNEA CAP-MR DR. MAGNO A PNSS 1L AT 90 CC/HR
GILBERT
CKD SECONDARY TO DKD D LOW SALT LOW FAT DIABETIC DIET

TYPE 2 DM-NIR M VS Q 4 HRS

HYPERTENSIONS STAGE 2 I ceftri day 2, azith day 2

1. AMLODIPINE 10MG/TAB OD

2. ASPIRIN 80MG/TAB OD

3. LINAGLIPTIN/METFORMIN 2.5MG/ 500MG TAB OD

4. IRBESARTAN 300MG/TAB, 1 TAB OD

6. KETOANALOGUE 1 TAB TID

7. CARVEDILOL 6.25MG/TAB BID

8. FEBUXOSTAT 40MG/TAB OD

9. SIMVASTATIN 40MG/TAB OD HS

10. CEFTRIAXONE 2G IV NOW THEN OD

11. AZITHROMYCIN 500MG/TAB, 1TAB OD X 5 DAYS

12. BISACODYL 10mg 1 supp now

13. NAC 1 tab in ½ glass water OD HS

09/05 no new labs

09/04

CXR BILATERAL LOWER LOBE PNEUMONIA

MAGNIFIED CARDIAC SHADOW CARDIOMEGALY IS NOT

RULED OUT. ATHEROSCLEROTIC AORTA

ABG- PH 7.44 pco2 24.8 po2 59.5 hco3 17 be -4.7 o2

sat 92% po2 0.5

Mg 0.75

Hba1c 6.5
 Bun 10.9

Ca 1.21

Crea 137

Sgpt 71

Uric acid 463

Na 143.1

K 3.95

09/05 3:30pm

NAC 600MG 1 TAB AT ½ GLASS H2O OD

SALBU + IPRA (DIOCENT) 1 NEB NOW THEN Q8

ADMIT

08/27/23 10 DELA CRUZ, 66/F LEFT SIDED 8/28 DR ANUTA A IVF PNSS 1L AT 100CC/HR
EUFEMIA WEAKNESS
RIGHT FRONTAL LOBE MASS D LSLF, DD

T2 DM M NEURO VS Q4, I AND O Q SHIFT

HYPOTHYROIDISM I CEFIXIME D5

U CPK (60KGS)

08/31 M

S/P CRANI0TOMY, EXCISION OF BRAIN TUMOR 1. ROSUVASTATIN 10 MG 1 TAB OD @ HS

2. METHIMAZOLE 5 MG 1 TAB OD

09/01 3. SITAGLIPTIN + METFORMIN 50/500 MG 1

TAB OD
GLIOMA AT R FRONTAL
4. CEFIXIME 200 MG 1 TAB BID X 7 DAYS
S/P CRANIOTOMY EXCISION OF TUMOR
5. LEVETIRACETAM 500 MG TAB 1 TAB PO BID
HPN STAGE II
6. NORGESIC FORTE 1 TAB TID X 2 DAYS
T2 DM
 HYPERTHYROIDISM PRN MEDICATIONS

1. CELECOXIB 200 MG 1 TAB BID FOR PAIN

09/04

GLIOMA AT FRONTAL L

S/P CRANIOTOMY EXCISION 09/05

HPN STAGE II NO NEW LABS

T II DM

HYPERTHYROIDISM 09/04

NO NEW LABS

09/05

MGH

09/04

FOR DISCHARGE NEURO

08/31/23 11 STRONG, JEFFERY 65/M NON DR. RASHID (PC) CM A: PNSS 1L AT 100 CC/HR IM/SURG
ALAN HEALING NON-HEALING ULCER, RIGHT LEG WITH CELLULITIS
WOUND DR. D D: DAT
BUENAVENTURA
T/C PERIPHERAL ARTERIAL DISEASE ON TOP OF CHRONIC (CM) M: VS Q4; I&O QSHIFT
VENOUS INSUFFICIENCY
I: CIPROFLOXACIN D5
ACUTE KIDNEY INJURY SECONDARY TO INFECTION
CLINDAMYCIN D5

U: (141KG)

09/04 M:

NON-HEALING ULCER, RIGHT LEG WITH CELLULITIS 1. CLINDALEV 600 MG IV Q8

2. CIPROFLOXACIN 400MG IV Q12

S/P DEBRIDEMENT
3. ALGESIA 1TAB Q4

4. OMEPRAZOLE 40 MG 1 TAB OD

5. TELMISARTAN 40 MG 1 TAB
 PRE OP MEDS

1. OMEPRAZOLE 40MG IV ONCE ON NPO

PRN MEDICATIONS

1. TRAMADOL 50 MG FOR PAIN IVTT

2. PARACETAMOL 300 MG IVTT

L:

09/04

NO NEW LABS

0/05

NO NEW LABS

U:

09/04

FOLLOW UP DUPLEX SCAN OF BOTH LEGS

CONTINUE MANAGEMENT

09/05

CONTINUE PRESENT MANAGEMENT

WILL RELAY DUPLEX RESULT TO AP

FACILITATE PLA OF OR TODAY

FOR COMPLETION OF IV ANTIBIOTICS TO D7

8/29/23 12 TAN, NESTOR 65/M NON SEVERE SEPSIS SECONDARY TO NECROTIZING FASCITIS CM A: PNSS 1L @ 120 CC/HR SURG/IM
HEALING T2DM, CAP-MR, HYPERTENSION STAGE II
WOUND ON D: AS TOLERATED
THE RIGHT
FOOT M: VS Q4; I&O QSHIFT

I:

U: I: 4440; O: 4490 CPK:1.8 (65 KGS)

M:

1. ROSUVASTATIN 10MG 1 TAB ODHS

2. METOPROLOL 100MG 1 TAB OD

3. AMLODIPINE 10MG 1TAB OD

4. CEFTRIAXONE 2G IVTT OD

5. CLINDAMYCIN 300MG Q6

6. RI 8U TID PRE MEALS

7. LACTULOSE 30CC OD @ HS

8. GLICLAZIE 60MG TAB OD

9. DOLCET 1 TAB TID

10. PREGABALIN 75MG 1 TAB ODHS

11. INSULIN GLARGINE 22 U SQ ODHS

12. NAC 600MG 1 TAB ODHS

13. CIPROFLOXACIN 200MG IV Q12

PRN MEDICATIONS

1. RI SLIDING SCALE

140-220 4 U SQ

221-260 6 U SQ

261-300 8 U SQ

>300 10 U SQ

2. RESCUE FOR PAIN AND ALSO DURING

SLEEPING TIME
 - TRAMADOL 50MG IVTT

- PARACETAMOL 300 MG IVTT

3. EPIDURAL ANALGESIA:

- LIDOCAINE 2% 5ML + 0.9 NACL 5ML PER

EPIDURAL CATHETER FOR SEVERE PAIN

L:

09/05

NO NEW LABS

U:

09/05

DECREASE GLARGINE TO 10U SQ OD - HOLD GLARGINE

INSULIN

CONTINUE RESCUE DOSE

CONTINUE MONITORING

NAC 600MG/ TAB +½ H20 OD HS

D/C CEFTRIAXONE

MAY START CIPROFLOXACIN (CIROK)200MG IVTT Q12

9/3/23 44 BACLAAN, LEAH 52/F SEIZURE GENERALIZED TONIC-CLONIC SEIZURE PROBABLY A D5W 1L @ 80 CC/HR IM
SECONDARY TO HYPONATREMIA SECONDARY TO GI LOSS
AND POOR ORAL INTAKE; HPN STAGE II IVF KVO

PNSS 80 CC/HR + OMEPRAZOLE 80 MG @ 10 CC/HR

D MAY HAVE SOFT DIET

M VSQHOURLY, I/OQHOURLY

U CPK 4.3 (48KGS)

1. MIDAZOLAM ½ AMP NOW

2. PANTOPRAZOLE
+DOMPERIDONE(PANTOPLUS) OD
LEVECITARETAM TO 500MG ½ TAB BID
 PRN MEDICATION

1. PARACETAMOL 300 MG IV Q4 PRN FOR

FEVER

09/05 1:15 PM

NA 141

9/4 NA 124

09/05 1:15 PM

REPEAT NA AT 8AM

DEC O2 TO PRN

MAY REMOVE NGT

LEVECITARETAM TO 500MG ½ TAB BID

MAYBHAVE SOFT DIET

MAY REMOVE FC

MAYBSTART PANTOPRAZOLE +DOMPERIDONE OD

NOW THEN PRE BF

C/D OMEPRAZOLE DRIP

FF UP REPEAT S. NA

09/04

SUGGEST TO DO CT SCAN CRANIAL PLAIN.

INCREASE IVF PNSS TO 80CC/HR

REPEAT S.NA AT 10PM AND RELAY RESULT

 STRICT I AND O MONITORING

CONTINUE PRESENT MANAGEMENT

9/3/23 15 JARABE, JUANITO 70/F HEMOPTYSIS T/C PTB RADICULOPATHY, RIGHT LEG CAP-LR A PNSS 1L @ 70CC/HR IM
SR
D LOW SALT, LOW FAT, LOW PURINE DIET

M VS QSHIFT, I/O Q4HOURS

I : CEPODOXIME D2

U CPK (65KG)

1. CLOPIDOGREL 75MG/TAB OD

2. AMLODIPINE 10 MG/TAB OD

3. ATORVASTATIN 10MG/TAB OD HS

4. COLCHICINE 0.5MG/TAB, 1 TAB BID

5. FEBUXOSTAT 40MG/TAB 1 TAB OD

6. NORGESIC FORTE TAB, 1 TAB TID

7. PREGABALIN 75MG/TAB, 1 TAB BID

8. DOLO NEUROBION TAB, 1 TAB OD

9. CEFPODOXIME 200MG/TAB, 1 TAB BID TO

COMPLETE 7 DAYS

10. TAMSOLUSIN HCL + FINASTERIDE 200MCG/5MG

TAB OD

11. HRZE 4 TABS 30MINS BEFORE BFAST

12. DOLCET 1 TAB Q8

13. TRAMADOL + PARACETAMOL 1 TAB Q8

14. MELOXICAM 7.5MG 1 TAB OD

09/04
NO NEW LABS

09/05

NO NEW LABS BUT FOR GENE XPERT

09/04

FACILITATE SPUTUM GENE XPERT

09/05

START HRZE 4 TABS 30MINS BEFORE BREAKFAST

C/D IVF
09/05/23 39 BADA, JUANITO 82/M DIFFICULTY PULMONARY MASS, RIGHT T/C MALIGNANT DR. GALICIA (PC) A: PNSS 1L AT 60CC/HR
OF HYPERTENSION STAGE 2
BREATHING D LOW FAT LOW SALT DIET

M VS Q4 I AND Q SHIFT

2. LOSARTAN 50 MG 1 TAB OD

U
09/02/23 40 AVILA, GINA 58/F VOMITING T/C CATHETER RELATED BLOOD STREAM INFECTION DR. QUIREQUINCIA A: PNSS 1L @ KVO
(PC)
UREMIC GASTROPATHY D RENAL DIET

ESRD SECONDARY TO DKD M CBG TID PREMEALS

HYPERTENSION STAGE 2 I: VANCOMYCIN D1

TYPE 2 DIABETES MELLITUS NIR U: I: 1640 O: 10 (56 KG)

1. TRIPLIXAM 10 MG/2.5 MG/10 MG OD

2. CARVEDILOL 6.25 MG 1 TAB BID

3. CLOPIDOGREL 75 MG OD

4. NAHCO3 650 MG TID

5. LINAGLIPTIN 5 MG OD

6. EPO 4000 IU POST HD

7. PIPTAZ 2.25 G IV Q6

8. CLONIDINE 150 MCG 1 TAB Q8

9. VANCOMYCIN 1G IV LOADING DOSE

10. DONPERIDONE 10 MG/TAB TID

11. PANTOPRAZOLE 40 MG/TAB BID

12. NIFEDIPINE 30G

PRN MEDICATIONS

1. METOCLOPROMIDE 10 MG 1 AMP Q8 FOR

VOMITING

2. PARACETAMOL 300 MG IV Q4 FOR FEVER

AND CHILLS

3. CLONAZEPAM 2 MG / TAB ½ TAB OD @ HS

PRN

09/05

NO NEW LABS
 09/04

NO NEW LABS

09/05

START NIFEDIPINE 30MG 1 TAB NOW

REPEAT HD TOMORROW

REUSE DIALYZER 2X

09/04

CONTINUE TITRATION OF NICARDIPINE DRIP

CONTINUE ANTIBIOTICS FOR NOW

FF UP OFFICIAL CULTURE RESULTS

08/22/23 43 ALMONIA, 62/F BODY PULMONARY CONGESTION SECONDARY TO AKI SEC TO CIN DR. LACUNA A: PNSS 1L TO 60CC/HR
THELMA WEAKNESS ON TOP OF SEPSIS (IMPROVING)
D SD
CAP-MR RESOLVING
M VS Q4 IO QS
SOLID MASS WITH INFILTRATES
I CEFEXIME D5
MEI: DECREASE NA, K - RESOLVING
U: CPK (58KG)
T2 DM IR
M 8/25

1. ATORVASTATIN 20MG/TAB OD HS

2. METHIMAZOLE 5MG 1 TAB BID

3. CACO3 + VIT D 1 TAB OD X 1 WEEK

4. GLARGINE 14 UNITS SQ OD

5. AMLODIPINE 10 MG 1 TAB OD

6. CARVEDILOL 6.25 1 TAB BID

7. TRIMAG 1 TAB TID FOR 1 WEEK

8. KCL TID FOR 3 DAYS

 9. CEFEXIME 400 MG 1 TAB OD

PRN MEDICATIONS

1. RI SLIDING SCALE

2 UN 180-220

4 U 221-240

6 U 241-260

8U 261-300

10 U >300

2. TRAMADOL 50 MG IV PRN FOR PAIN

3. D50 1 POLYAMP FOR CBG < 100MG/DL

L:

09/05 3:10 pm

No new labs

09/04

CXR

IMPRESSION

BILATERAL PNEUMONIA WITH MINIMAL PLEURAL

EFFUSION

UNDERLYING METASTATIC IS NOT RULED OUT IN THR

PRESENCE OF BOTH LUNGS

ATHEROSCLEROTIC AORTA

09/05 3:10pm

MGH STILL IN CONTINUE ORESSNT MANAGEMENT AND

MONITORING WHILE IN
 DECREAS O2 to 1LPM VIA NC

WOF FOR DESAT <94

FOR STRICT ASPIRATION PRECAUTION

09/04

TOS BACK TO DR.ORCSSITAS

DEC O2 SUPPORT TO 3LPM

DEC IVF RATE TO 40 CC/HR

WILL DISCHARGE PT IF CLEARED WITH OTHER SERVICES

DC DEXAMETHASONE

08/28/23 14 DAITOL, 54/M LEFT SIDED 09/04 DR. MAGNO (PC) A : PNSS 60 CC/HR IM
ARTERMIO WEAKNESS
ACUTE CVA BLEED, RIGHT EXTERNAL CAPSULE ON TOP OF DR. ANUTA (CM) D ENSURE MILK 1600KCAL IN 6 DIVIDED FEEDINGS
MULTIPLE CHRONIC INFARCTS
M VSQ4, I&O QS
CAP-MR
I CEFIXIME 200 MG 1 TAB BID D2
HCVD
U: 1.7CPK `(55 KG)
CKD SEC TO HPNO
M

1. TELMISARTAN 80 MG TAB OD

2. AMLODIPINE 10 MG TAB OD

3. EDVARONE 30 MG/20 ML IV TO RUN FOR

30 MINS Q12

4. ATORVASTATIN 80 MG 1TAB ODHS

5. LEVETERACETAM 100 MG/ML BID

6. CEFIXIME 200 MG 1 TAB BID

7. BISOPROLOL 5 MG 1 TAB OD

8. CLONIDINE 150 MCG 1 TAB BID (HOLD IF

BP IS <120MMHG)

09/04
 NO NEW LABS

09/05

CBG 5AM: 121 NG/DL

09/04

START CLONIDINE 75 MCG 1 TAB TID, HOLD IF SBO IS

KESS THAN 120MMHG

START DOWN TITRATING NICARDIOINE DRIP

DC MANNITOL

DEC CLONIDINE TO 75MCG 1 TAB BID

09/05

DECREASE NICARDIPINE DRIP TO 3CC

TRIAL FEEDING JELLY ACE

DO BLADDER TRAINING

08/04/23 46 MORING, FELIX 57/M RIGHT SIDED ACUTE CVA INFARCT VS BLEED DR.M. ALQUIZA A PNSS1L REGULATE AT 80 CC/HR
WEAKNESS
TYPE 2 DIABETES MELLITUS D DAT

HYPERTENSION STAGE 2 M VS Q4HRS; I/O QSHIFT

U CPK

1. CILOSTAZOL 100MG 2 CAPS OD HS

2. CITICOLIN 1 GM IV NOW THEN Q12HRS

3.PIRACETM 1.2G 1 TAB

4.ATORVASTATIN 80MG/TAB OD HS

5. CEREBROLYSIN 10 MG IV Q12

6. EDARAVONE 30MG + 20CC PNSS X 30MINS Q12

7. PANTOPLUS 40/30MG OD

8. METOCLOPRAMIDE 10MG IVTT NOW THEN Q8HRS

PRN FOR VOMITING

9.PLETAAL SR 100MG 2 CAP OD HS

START RI SLIDING SCALE

A) 4 UNITS RI SQ FOR CBG > 180

B) 6 UNITS RI SQ FOR CBG > 220

C) 8 UNITS RI SQ FOR CBG > 260

D) 10 UNITS RI SQ FOR CBG > 300

09/05 1:40 PM

HBA1C 10.6

URIC ACID 693

CHOL 6.1

HDL 1.40

LDL 3.98

TGL 1.67

09/05 1:40 PM

CONTINUE ALLOW PERMISSIVE HYPERTENSIN

WOF NEW NEUROLOGIC DEFICITS

SUGGEST FOR CRANIAL MRI

CONTINUE MEDS

ONCREASE CILOSTAZOL TO 100MG 2 CAPS OD HS

 FOR HBA1C

09/02/23 47 ARISGADO, 75/F BODY MALAISE HYPERGLYCEMIC CRISES (HHS) DR. HO A PNSS 1L @ 100 CC/HR
CERINA
T/C UROSEPSIS SEC TO COMPLICATED UTI D NPO

TYPE II DM - UNRECALLED M VS Q4, I AND Q SHIFT, CBG Q HOURLY

I: CEFTRIAXONE D2

U CPK (65KG)

1. CEFTRIAXONE 2 GMS IV OD

2. RI 20 U SQ TID PRE - MEALS

3. FEBUXOSTAT 40 MG 1 TAB OD

4. SENOKOT FORTE 1 TAB OD

5. GLARGINE 44 U SQ OD

6. LOSARTAN 50MG 1 TAB OD

7. ESOMEPRAZOLE 40MG 1 TAB OD

STAT MEDICATIONS

PRN MEDICATIONS

1. PARACETAMOL 500MG 1 TAB Q4 PRN FOR

FEVER > 38 C

2. RI 6 U 180 - 220

RI 8 U 221 - 260

RI 10 U > 260

09/05 12:30 PM

URINE CS - NO GROWTH AFTER 48 HOURS OF

INCUBATION
 CBG 6AM 267MG/DL

09/04

SUA 374

09/05 12:30 PM

FACILITATE USD OF WA

FF UP BLOOD CS AND URINE CS

09/04

FEBUXOSTAT 40MG/TAB OD

HNBB 1 AMP Q8 PRN FOR ABDOMINAL DISCOMFORT

INCREASE GLARGINE RO 32 U

DECREASE RI TO 18U SQ TID

FOR USD OF WA

GEN MED III: 11

DATE RM PATIENT’S NAME AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FOR REMARKS SERVICES
ADMITTED SEX COMPLAINT REFERRAL

9/5/23 18 GUERRA, 48/F LOWER HYPOKALEMIC PERIODIC PARALYSIS DR. ORCASITAS A

CHONA EXTREMITY
RIGHT ARM: PNSS 1L80CC/HR SIDEDRIP KCL DRIP 60MEQS +
WEAKNESS BRONCHIAL ASTHMA – CONTROLLED 250CC PNSS @ 40CC/HR X 2 CYCLES

LEFT: PNSS 1L @ KVO SIDEDRIP 1: NAHCO3 100MEQS + 250CC

D5W @ 20CC/HR

SIDEDRIP 2: TO FOLLOW PNSS 250 CC + 40 MEQS KCL @

20CCC/HR

D DAT WITH 1 BANANA PER MEAL

M VS Q4, I/O QSHIFT

U 1.3 CC/KG/HR(61KGS)

1. SYMBICORT RAPIHALER 160/4.5 2 PUFFS Q12 GARGLE AFTER

2. MONTELUKAST 10 MG 1 TAB OD HS

3.KCL 2 TAB QID

4.OMEPRAZOLE 40MG TAB OD

9/5

CBC

WBC 20.5

RBC 4.3

HGB 14.0

HCT 0.40

PLT CT 253

N 0.94

L 0.05

M 0.01

E 0.00

B 0.00

NA 144.3

K 2.21

MG 0.97

CA 1.25

CREA 99

XRAY: NORMAL CHEST FINDINGS

 12 LEAD ECG

RAT RT PCR: NEGATIVE

UA:

LIGHT YELLOW

CLEAR

6.5

1.010

NEGATIVE

9/5

ADMIT

REVISED KCL DRIP

FOR REPEAT SERUM K GHOURS POST 2ND CYCLE OF KCL DRIP

FOR STRICT I&O MONITORING

FOR FT3 TOMORROW

09/05/23 RM LLOREN, JOEL 54/M RUQ PAIN CHOLEDOCHOLITHIASIS DR. VELASCO (PC) A D5NSS 1L AT 100CC/HR IM

19 D LOW FAT DIET

GM3 M VS Q4HRS; I/O QSHIFT

U CPK

1. VITAMIN K 10MG IN 50ML NSS IN SOLUSET TO RUN

IN 30 MINS Q8HRS

2. AMPICILLIN + SULBACTAM (AMSULVEX 1.5MG IVTT

Q8HRS (TO START AT ER)

3. DOLCET TABLET, 1 TABLET EVERY 8HRS AS NEEDED

FOR PAIN

4. PANTOVEX 40MG IVTT AT 6AM ON THE DAY PRIOR

TO ERCP

L
 09/05

WBC 6.9

RBC 4.0

HGB 12.4

HCT 0.38

PLT CT 257

N 0.79

L 0.15

M 0.04

CXRAY

NEGATIVE CHEST XRAY

PROTIME

09/05

09/01/2023 20 FERRARIS, 90/F COUGH COMMUNITY ACQUIRED PNEUMONIA - MODERATE RISK DR. LACUNA (PC) A PNSS @ 10CC/HR
FLORDELIZA WITH ASPIRATION COMPONENT
D LSLF
HYPERTENSIVE CARDIOVASCULAR DISEASE
M VSQ4, I&O QSHIFT

I PIPTAZ D0+2

U: 0.9 CC/KG/HR (64KGS)

1. PIPERACILLIN + TAZOBACTAM 4.5 GM IV

INFUSION Q8

2. MOXIFLOXACIN 400MG/TAB OD

3. BISOPROLOL 2.5 MG 1 TAB OD

4. CALMAG 1 TAB BID

5. NAC 600 MG TAB 1 TAB BID

 6. SALBU + IPRA +2CC PNSS Q6

09/05

WBC 6.0

PLT CT 189

RBC 5.5

HGB 16.3

S 0.62

HCT 0.49

L 0.21

M 0.09

E 0.07

B 0.01

09/05

PLEASE FACILITATE SPUTUM GSCS, KOH GENE XPERT

CONTINUE PRESENT MEDICATION

9/4/22 LIMPANGOG, 51/M DYSPNEA PULMONARY CONGESTION SECONDARY TO CHF DR. MAGALLANES A PNSS 1L AT KVO IM
ORLY
FC II D DAT

M VSQ4

U 1.3 CC/KG/HR (53.5KG)

1. ASPIRIN 80MG TAB 1 TAB OD

2. CLOPIDOGREL 76MG TAB 1 TAB OD

 3. ENOXAPARIN 0.6CC SQ Q12

4. PANTOPRAZOLE 40MG 1 TAB OD

5. FUROSEMIDE 20MG Q12

6. SPIRONOLACTONE 25MG TAB OD

7. ATORVASTATIN 40MG TAB 1 TAB OD

8. FEBUXOSTAT 4OMG TAB 1 TAB 0D

9. ATROVENT NEB Q6

09/05

TROP 150.8

09/05

PLEASE RETRIEVE CXR FILM, RELAY ONCE AVAILABLE

FF UP CARDIO REFERRAL

MAINTAIN IVF AT KVO

LIMIT OFI TO 1.5L/DAY

START I&O MONITORING WITHOUT FAIL

FACILITATE UA, LIPID PROFILE AND FBS

CBR WITHOUT BP

09/05/23 22 DIONGSON, 86/M DECREASED Acute CVA Infarct prob posterior Cerebral artery NIHSS - 8 Dr. Licayan (PC) Dr. A PNSS 1L @ 100 cc/hr
AMIE SENSORIUM HCVD Abou zaki (CM)
D Soft diet with strict aspiration precaution

M VS q4, NVS 4, I and O q shift

U 0.6 CC/KG/HR(70KGS)

1. Atorvastatin 80 mg 1 tab OD HS

2. Citicoline 1 gm IV q 12

3.CARVEDILOL 6.25MG TAB BID

4.OMEPRAZOLE 40MG TAB 1 TAB OD

SENOKOT FORTE 1 TAB OD HS

09/05

CRANIAL CT SCAN PLAIN

IMPRESSION:

ACUTE NON-HEMORRHAGIC INFARCT, RIGHT

OCCIPITAL LOBE

CHRONICE INFARCT, LEFT PARIETAL LOBE

CEREBRAL AND CEREBELLAR ATROPHY

BILATERAL INTERNAL CAROTID AND VERTEBRAL

ATHEROSCLEROSIS

CHRONIC MAXILLARY SINUSITIS,LEFT

CXR

IMPRESSION:

PULMONARY CONGESTION

LEFT VENTRICULAR CARDIOMEGALY

ATHEROSCLEROTIC AORTA

THORACIC SPONDYLOSIS

CBC

WBC 12.0

RBC 5.5

HGB 16.5

HCT0.49

PLT 230

N 0.84

L 0.09
 M 0.04

E 0.02

B 0.01

MG 0.65

CA 1.12

CREA 101

K 3.08

NA 142.7

FT4 0.98

TSH

SUA 535

HBA1C 5.5

09/05

Conferred with Dr. Licayan

Start Amiodarone 200 mg 1 tab TID

Refer to Dr. Abuo zakit for co-mgt

9/3/23 23 PADON, VICTOR 85/M LOSS OF PTB - CLINICALLY DIAGNOSED DR. QUIAMBAO A PNSS 1L AT KVO
APPETITE
T/C PULMONARY MASS D DAT

M VS Q4 HRS, I/O QHOURLY

U 1.5 CC/KG/HR (57KG)

1. HRZE TABS OD- HOLD

2. VIT B COMPLEX 1 TAB OD

3. DOXOFYLLINE 400 MG/TAB, 1/2 TAB BID

4. NAC 600 MG/SACHET OD HS

 5. LEVOCETIRIZINE/MONTELUKAST 5/10MG
OD HS

6. OMEPENTINE 40 MG IV OD

7. MOSEGOR VITA 1 TAB OD HS

8. LEVOPRONT 10 ML TID

9/05

PT

TIME

PT 13.3 CONTROL 11.7

INR 1.13

% ACT 79.00

9/05

INCLUDE ALT ON NEXT BLOOD EXTRACTION

FACILITATE CT SCAN WITH CONTRAST OF THE CHEST

SCHEDULE FOR LUNG BIOPSY TOMORROW 10-11AM

(9/6)

REFER IN PATHO FOR FS

PLS NEED VIDEOS OF CT SCAN

09/02/23 24 ALENTAJE, ANNE 32/F FEVER AND BACTEREMIA SOURCE TO BE DETERMINED PROBABLY DR. S. GUILLERMO A IVF PNSS 1L AT 80CC/HR
CHILLS SECONDARY TO UTI
D DAT

M VS Q4, I AND O QSHIFT

09/05
I CEFTRIAXONE D2
S. AUREUS BACTEREMIA
 R/O BACTERIAL ENDOCARDITIS U 1.5 CC/KG/HR (49KG)

1. CIPROFLOXACIN 400MG MG IV Q12

PRN MEDICATIONS

1. PARACETAMOL 300MG TAB, 1 TAB Q4

PRN FOR FEVER

09/05

CS: + STAPH AUREUS

09/05

SUGGEST FOR 2DECHO

SHIFT CEFTRIAXONE TO CIPROFLOXACIN 400 MG IV

Q12

9/4/23 25 PELIGOR, BENCIL 33/M COUGH DR. ALEJANDRO A PNSS AT 200CC/HR

CAP-MR D LOW SALT, LOW FAT

OBSTRUCTIVE JAUNDICE VS ACUTE HEPATITIS M VSQ4, I&O Q4

I CEFTRIAXONE 2GM IV NOW THEN OD

AITHROMYCIN 500MG 1 TAB OD

U 0.7 CC/KG/HR(75KGS)

CEFTRIAXONE 2GM IV OD

AZITHROMYCIN 500MG TAB OD

NAC 600MG TAB OD

KCL TAB A TAB TID X 6 DOSES

PARACETAMOL 500MG TAB OD PRN FOR FEVER

DOLCET 1 TAB PRN FOR HEADACHE

L:

09/05

UTZ OF WA

GALLBLADDER WALL EDEMA, PLEASE CORRELATE CLINICALLY

SONOGRAPHICALLY NORMAL LIVER, BILLIARY TREE, PANCREAS,

SPLEEN, PARA-AORTIC REGIONS, KIDNETS, URINARY BLADDER
AND PROSTATE

URINALYSIS

WBC 1

RBC 15

EPITH CELLS 3

CAST 0

BACTERIA 1

PE

COLOR DARK YELLOW

CHARACTER CLEAR

REACTION: 6.0

SPECIFIC GRAVITY: 1.02

CE

SUGAR: NEG

PROTEIN +

U
 09/05

FOLLOW-UP HEPA PROFILE TEST

FOR HBSAG QUANTI

ANTIBIOTICS

FACILITATE ULTRASOUND WHOLE ABDOMEN

9/4/23 27 CORPUZ, 51/F LEFT LOWER HYPOVOLEMIC SHOCK PROB SECONDARY TO ACUTE DR. P. A: PNSS 1L AT 100CC/HR IM
JOCELYN QUADRANT BLOOD LOSS SEC TO BLEEDING. BUENAVENTURA (PC)
PAIN D: DAT, INCLUDE 2 EGG WHITES PER MEAL
RECTOSIGMOID MASS ON TOP OF SEPTIC SHOCK SEC TO
UROSEPSIS RECTOSIGMOID ADENOCARCINOMA M: VS Q4HRS; I/O QSHIFT

I:

U: 50KG

M:

1. CEFTRIAXONE 2G IV NOW THEN OD

2. TRANEXAMIC ACID 1GM IV Q8

3. NAC 2 TAB BID

PRN MEDICATIONS

1. TRAMADOL 50MG IV PRN FOR PAIN

2. PARACETAMOL 500MG 1 TAB PO Q4 FOR

PAIN

L:

09/05

NO NEW LABS

U:

09/05

RESCHEDULE CT SCAN TOMORROW

CASTOR OIL 30CC BY 3 PM & ANOTHER BY 8PM

FOR REPEAT CBC 6 HOURS AFTER 3RD UNIT PRBC

08/29/23 29 DONDOYANO, 54/M BLEEDING HYPOVOLEMIC SHOCK SEC TO ACUTE BLOOD LOSS SEC TO DR. HO A IVF PNSS 1L @ 10 CC/HR
JOSE OROPHARYN BLEEDING OROPHARYNGEAL MASS LEFT -
GEAL MASS DR. LAGANAO (CM) MORPHINE DRIP: PNSS 95CC + MORPHINE 50MG TO
UNDIFFERENTIATED SQUAMOUS CELL CARCINOMA RUN @ 3CC/HR

TYPE II DIABETES MELLITUS NON-INSULIN REQUIRING D PEG TUBE FEEDING: GLUCERNA 235 CC THEN
FLUSHE WITH 60 CC WATER, Q 4
HYPERTENSION STAGE II
M VS Q 4, I&O Q SHIFT
MAJOR DEPRESSIVE DISORDER
I

U:

1. KENZOLIN 4.5G IV Q6

2. METFORMIN 500MG 1 TAB BID

3. VALPROIC ACID 500MG TAB 1 TAB BID

4. VINEGAR 1:1 DILUTIOM C PNSS 10CC TO

SWISH AND SPLIT BID

5. NAC 600MG TAB OD HS

6. TRANEXXAMIC ACID 500MG TAB 1 TAB Q8

STAT MEDICATIONS

1. MORPHINE 1MG RESCUE DOSE

2. TRANEXAMIC ACID 1 GM IV NOW

PRN MEDICATIONS

1. RI SLIDING SCALE

4U FOR CBG 181-220

6U FOR 221-260

8U FOR > 260

2. MORPHINE 1MG IVTT BOLUS AS RESCUE

DOSE

3. DOSE FOR BTP

 L

09/05

CREATININE 65

ECG

NORMAL ECG

09/05

FOLLOW-UP CONSENT FOR REFERRAL TO ONCO

SUGGEST FOR REPEAT CXR

FOR BLOOD CS AND SPUTUM CS

FOR TRACHEAL ASPIRATE C/S

09/05/23 30 Revilla, Narciso 74/M Edema Pulmonary congestion prob secondary to Heart failure DR. OMBAO (HC) A PNSS @ KVO

Chronic Venous Insufficiency D low salt Low fat, DM

Hypertensive Cardiovascular Disease, Heart Failure FC III MVS q4, I/O q shift

Anemias prob sec to CKD sec to DKD/ HKD I

T2 DM U 0.4 CC/KG/HR (95KGS)

S/P CVA with left sided residual weakness M

1. Albumin 20% + 40 mg Furosemide x 4 hours q 12

hours (congestion precaution)

2. Mg so4 2 gm + 20 cc NSS slow iv q8 x 2 doses

3. Trimag 1 tab TID

4. RI Sliding scale

CBG RI SQ

180-220 4 units

221-260 6 units
261-300 8 units

>300 10 units

09/05

CBG 130 mg/dl

ECG Sinus tachycardia, RBBB incomplete

WBC 9.7

Hgb 8.8

Hct 0.26

Plt 244

N 0.71

L 0.20

M 0.08

Albumin 18

Creatinine 181 (egfr 33)

SUA 491

Na+ 137.0

K+ 3.92

Ca++ 1.17

Mg+ 0.57

Pro calcitonin 0.13

 U

09/05

08/27/23 31 CAÑEDA, 22/M STIFFENING 09/05 DR. ANUTA (PC) A: C/D IVF SHIFT TO HEPLOCK IM
MAROEL
RPGN D: DAT

GENERALIZED SEIZURE DISORDER SEC TO METABOLIC M: VS Q4; I&O QSHIFT; NEURO VS Q4

ENCEPHALOPATHY
I:

U: (60 KG)

M:

1. LEVETIRACETAM 500MG/TAB Q12

2. CALMAG 1 TAB BID

3. KCL 1 TAB TID X 3 DAYS

4. PANTOPRAZOLE 40MG 1 TAB OD

5. FEBUXOSTAT 40MG/TAB OD

6. NAHCO3 650MG/TAB OD

7. AMLODIPINE 5MG/TAB 1 TAB OD

PRN MEDICATIONS

1. NORGESIC FORTE TAB, 1 TAB Q8 PRN FOR

BACK PAIN

2. METOCLOPROMIDE PRN FOR VOMITING

L:

09/05

NO NEW LABS

U:
 09/05

CONTINUE PRESENT MANAGEMENT WHILE STILL IN

FF UP DR. TAN AS OPD

FF UP ANTI-DSDNA AS OPD

08/12/23 32 TAJORA, 89/F COUGH 09/05 DR. LACUNA (PC) A: PNSS 1L @ 10 CC/HR IM
JACINTA
PLEURAL EFFUSION RIGHT DR. J. RAMOS (CM) D: SOFT DIET WITH STRICT ASPIRATION PRECAUTION,
LIBERAL SALT DIET
PROBABLY SECONDARY TO PTB VS MALIGNANCY R/O ACS DR. FAJARDO (CM)
M: VSQ4, I&O QS
DR. QUIBO (EVAL)
I:

U: 1.0 CPK (50KGS0)

M:

1. CALMAG 1 TAB BID

2. SALBU + IPRA NEB Q8

3. NAHCO3 1 TAB TID

4. ZYKAST 1 TAB OD @ HS

5. AMLODIPINE 10MG 1 TAB OD

6. KCL 2 TABS TID

7. OMEPRAZOLE 40 MG 1 CAP OD

8. CARVEDILOL 25MG 1 TAB BID

9. METHYLPREDNISONE 16MG/TAB 1 TB BID

10. ENOXAPARIN 0.4 CC SQ OD

11. CLOPIDOGREL 75MG TAB1 TAB OD

12. ASPIRIN 80MG TAB 1 TAB OD

13. TRIMETAZIDINE 35MG TAB 1 TAB BID

14. ATORVASTATIN 80MG TAB 1 TAB OD HS

15. ISMN 30MG TAB 1 TAB OD

16. MEROPENEM 50MG IV Q12

17. PARACETAMOL 300MG IV Q4 X 3 DOSES

 THEN PRN

PRN MEDICATIONS

1. DOLCET 1 TAB BID

2. METOCLOPRAMIDE 1 AMP PRN FOR N/V

3. PARACETAMOL 300MG IV PRN FOR PAIN

L:

09/05

ABG

PH 7.42

PCO2 58.5

PO2 80.8

HCO3 39.0

02 SAT 95.7%

PO2 1.0

CREA 399

TROP I 168.4

U:

09/05

KEEP THERMOREGULATED

FOR SPUTUM GSCS

HOOK TO PULSE OXIMETER AT BEDSIDE

MAINTAIN BIPAP SETTINGS

REFER TO DR. OMBAO FOR CO MNGT

09/06/23 34 MALABON, 64/M BACK PAIN LUMBAR SPRAIN R/O FRACTURE DR. J. RAMOS (PC) A: PNSS 1L AT 50CC/HR IM
PEDRO
PULMONARY MASS, RIGHT D: DAT

M: VS Q4; I&O QSHIFT

I:

U: 1.0CC/KG/HR (49 KGS)

M:

1. TRAMADOL 50MG IV NOW THEN Q8 FOR SEVERE

PAIN

2. NORGESIC FORTE 1 TAB Q8

L:

09/05

WBC 12.4

RBC 5.0

HGB 14.4

HCT 0.45

PLT 268

N 0.75

L 0.12

E 0.06

M 0.05

B 0.01

CREA 81

U:

09/05
 PICU: 0

DATE RM PATIENT’S AGE/ CHIEF COMPLAINT ADMITTING DIAGNOSIS PHYSICIAN REASON REMARKS SERVICES
ADMITTED NAME SEX FOR
REFERRAL

FAMILY MEDICINE WING: 7

DATE RM PATIENT’S AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FOR REMARKS SERVICES
ADMITTED NAME SEX COMPLAINT REFERRAL

08/30/23 217-A TAYO, JASNA 25/F FATIGUE END STAGE RENAL DISEASE SECONDARY TO DR. MANALAYSAY A NO IVF IM
GLOMERULONEPHRITIS SECONDARY TO HYPERTENSION (PC)
D RENAL DIET
DR. DEL FIERRO
M VSQ4, I&O QS, WITH IJ CATH RIGHT NECK
FINAL DIAGNOSIS (IJ CATH)
I
END STAGE RENAL DISEASE SECONDARY TO CHRONIC
GLOMERULONEPHRITIS; STATUS POST INTRA JUGULAR U 0.9 CPK (73 KG)
CATHETER INSERTION RIGHT; STATUS POST INITIATION
HEMODIALYSISGLOMERULONEPHRITIS SECONDARY TO M
HYPERTENSION

1. EPO BETA 5000 IU SQ 3X A WEEK

2. IV IRON SUCROSE INTRA HD X 10 DOSES

3. AMLODIPINE + LOSARTAN 5/50 MG TAB

OD

4. NAHCO3 650 MG TAB TID

5. CA+VIT D TAB OD

L: 9/5

U: 9/5

MGHSI
09/05/23 217-C HINGGOS, 64/M NON HEALING NON HEALING WOUND, LEFT ANTERIOR SHIN DR. RJ TAN (PC) A PNSS 1L @ 100 CC/HR IM
ANECITA WOUND, LEFT
ANTER TYPE II DIABETES MELLITUS D DD, ALLERGIC TO SEAFOOD AND CHICKEN

M VSQ4, I&O QS

I PIP TAZO D0

U 1.0 CPK (75 KG)

1. PIPERACILLIN + TAZOBACTAM 4.5G IV Q6

2. METFORMIN 500MG 1 TAB OD

L 9/5

U 9/5

FOR AV DUPLEX SCAN OF LOWER EXTREMITIES

FACILITATE X RAY OF LEFT LOWER LEG APL

09/04/23 218-C BAYRON, 35/F LABOR PAIN T2DM - INSULIN REQUIRING DR. ROY (PC) A NO IVF OB/IM
MAYLEN
G3P1 (1011) PU 38 2/7 WEEKS AOG DR. EVORA (CM) D LSLF DIABETIC DIET

CHRONIC HPN T/C PREECLAMPSIA M VSQ4, I&O QS, CGB QID

I SULTAMICILLIN D0+1

FINAL DIAGNOSIS U CPK (KG)

GRAVIDA 3 PARA 2 (2012) PREGNANCY UTERINE DELIVERED M

TERM CEPHALIC LIVEBIRTH BABY BOY APGAR SCORE 8,9
BIRTHWEIGHT OF 2540GRAMS BALLARD SCORE 38-40 1. SULTAMICILLIN 750MG 1 TAB BID
WEEKS VIA SPONTANEOUS VAGINAL DELIVERY WITH
EPISIOTOMY AND REPAIR OF FIRST DEGREE PERINEAL 2. MEFENAMIC ACID 500MG 1 TAB Q6
LACERATION UNDER LOCAL ANESTHESIA; CHRONIC
3. AMLODIPINE 10MG 1 TAB OD
HYPERTENSION; DIABETES MELLITUS TYPE II -INSULIN
REQUIRING; ADVANCED MATERNAL AGE; CORD
4. METFORMIN 500MG 1 TAB TID
COMPLICATION

L 9/5

WBC 22.1, RBC 4.2, HGB 12.1, HCT 0.37, PC 203, N 0.74,
L 0.22, M 0.03, B 0.01
 U 9/5

MGH OB WISE

REPEAT CBC

RELAY CBC RESULT PRIOR TO DISCHARGE

CBG MONITORING BID QID PRE-BREAKFAST AND 2

HOURS AFTER ALL MEALS

08/27/23 221 MONDAY, 81/M DYSPNEA ASTHMA-COPD OVERLAP IN ACUTE EXACERBATION DR. J. RAMOS (PC) A PNSS 1L @ KVO IM
AGUSTO
CAP-MR DR. ORCASITAS D LSLF

HYPERTENSION STAGE II (PC 8/27-8/28) M VSQ4, I&O QS, O2 1 LPM/NC

DR. P I
BUENAVENTURA
9/5 (CM) U 2.1 CPK (67 KG)

COPD IN AE M

HTN STAGE II 1. DUODART 1 TAB OD

2. SALBU + IPRA NEB, 1 NEB Q8

3. DOXOFYLLINE 400MG TAB BID A:200MG

4. BUDESONIDE NEB 012 C/O RT

5. SOLUMEDROL 40MG IV Q6 A 500/8 (.64CC)

6. LACTULOSE 20ML ODHS 48

7. AVARIN 1 CAP TID

8. SENOKOT FORTE 1 TAB OD HS

9. BISOPROLOL 2.5MG 1 TAB OD

10. SPIOLTO 2PUFFS OD @HS

L 9/5

WBC 17.7, RBC 4.2, HGB 12.2, HCT 0.38, PLT 378, N 0.82, L
0.09, M 0.07, E 0.02, B 0.00

NA 141, K 3.39, MG 0.53, CA 1.16

 U 9/5

FF UP 2D ECHO RESULTS

09/02/23 223 AGUILAR, 81/F RIGHT LOWER ACUTE APPENDICITIS DR. AGUILAR (PC) A PNSS 1L @ 100 CC/HR IM
VEVENCIOLA QUADRANT
PAIN HYPERTENSION STAGE 2 DR. VALDEZ (CM) SD: D5W 250 CC + MGSO4 2 GM X 24 HOURS

AKI SEC TO INFECTION DR. BANICO (CP) D5W 500CC +TRAMADOL 200MG 20CC/HR

DR. ENOJO (CM) D LOW SALT, LOW FAT DIET

9/5 DR. C. GONZALES M VSQ4, I&O QS

RENAL MASS RIGHT WITH TUMORAL BLEED ( ANES) I

VS ABSCESS; DR. M. KASILAG U 2.7 CPK (70KG)

(CM&CV RISK
HYPERTENSION STAGE 2 STRATIFICATION) M

AKI SECONDARY TO INFECTION 1. LOSARTAN 50 MG TAB,1 TAB OD

2. ROSUVASTATIN 10 MG TAB, 1 TAB OD HS

3. CEFTRIAXONE 1.5 GRAM IV Q12 D5+1

4. OMEPRAZOLE 40MG IV OD

5. KCL TAB TID

6. METOCLOPRAMIDE 10MG IV PRN FOR

VOMITING

L 9/5

WBC 18.6, RBC 3.4, HGB 9.8, HCT 0.31, PC 352, N 0.81,L
0.09, M 0.08, E 0.02

CREA 100

U 9/5

RESCHED OR TO WEDNESDAY 09/06/23 AT 8 AM

FOR REPEAT 1 UNIT PRBC BLOOD TRANSFUSION

SECURE 3 UNITS PRBC FOR OR USE

09/01/23 224 PAMPLONA, 26/F FEVER DENGUE WITH WARNING SIGNS DR. QUIAMBAO A: PNSS 1L @ 100CC/HR IM
ANN VALERIE (PC)
D: DAT (NDCF)

9/5 M: VSQ4, I&O QS

DENGUE WITH WARNING SIGNS I:

U: 0.2 CPK (55 KG)

M:

1. PANTOPRAZOLE 40 MG IV OD

2. DOMPERIDONE 10 MG 1 TAB Q6 FOR GI

PAIN

3. NORGESIC 1 TAB Q6 PRN FOR HEADACHE

4. LIVERPRIME 1 TAB BID

5. ZYKAST 1 TAB OD

L: 9/6

WBC 11.6, RBC 4.4, HGB 12.2, HCT 0.36, PLT 60, N 0.37,
L 0.54, M 0.07, E 0.01, B 0.01

9/5

SGOT 96, SGPT 62

WBC 8.4, RBC 4.3 HGB 11.9, HCT 0.36, PC 57, N 0.34, L
0.57, M 0.09

U: 9/5

CBC Q8

09/01/23 224 PAMPLONA, 16/F FEVER DENGUE WITH WARNING SIGNS DR. QUIAMBAO A: PNSS 1L @ 100 CC/HR IM
PRECIOUS (PC)
D: DAT WITHOUT DARK COLORED FOODS

9/5 M:VSQ4 , I&O QS

DENGUE FEVER WITH WARNING SIGNS I:

U: 1.5 CPK (60 KG)

M:
 1. PARACETAMOL 500 MG 1 TAB Q4 PRN FOR
FEVER

2. PANTOVEX 40 MG IV OD

3. ZYKAST 10 MG TAB OD

4. DOMPERIDONE 10 MG 1 TAB Q6 PRN FOR

ABDOMINAL PAIN

L: 9/6

WBC 3.6, RBC 4.6, HGB 12.7, HCT 0.38, PLT 147, N 0.31,
L 0.59, M 0.09, E 0.01, B 0.00

U: 9/5

SURGICAL WING: 12

DATE RM PATIENT’S AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON REMARKS SERVICES
ADMITTED NAME COMPLAINT FOR
SEX REFERRAL

08/17/23 202-6 CAPOL, DAISY 46/F LEFT LOWER RECTOSIGMOID MASS DR. VALDEZ (PC) A: NO IVF SURG/IM
QUADRANT
AND SMALL UTERINE MYOMA DR. MAGNO (CP) D: DAT
HYPOGASTRIC
PAIN S/P CS DR. ONG- M: VSQ4, I&O QS
ABRANTES (TOS)
I:
DR. HAW (CM)
FINAL DIAGNOSIS U: 1.9 CPK (54 KG)
DR. PILAPIL (TSP)
PARTIAL INTESTINAL OBSTRUCTION SECONDARY TO M:
RECTOSIGMOID MASS TO CONSIDER MALIGNANCY DR. FUENTES (OFF)
1. DOLCET 1 TAB QID
DR. LINDO (ANES)
2. CAPTOPRIL 25MG 1 TAB SL IF BP >140/90

L: 9/5

U: 9/5
 MGHSI

08/19/23 203-1 BEBELONI, PIL 37/M DISCHARGE ON COLOCUTANEOUS FISTULA DR. PURACAN (PC) A: NO IVF SURG/IM
ANTHONY RLQ
S/P APPENDECTOMY DR. BANZON (ANES) D: FULL DIET

POTTS DISEASE DR. TORNO (EVAL) M: VSQ4, I&O QS

I:

FINAL DIAGNOSIS U: 0.8 CPK (71 KG)

COLOCUTANEOUS FISTULA WITH INTRA ABDOMINAL M:

ABSCESS

S/P APPENDECTOMY (2014)

L: 9/5
S/P DRAINAGE OF ABSCESS (2023)

POTT’S DISEASE
U: 9/5

MGHSI

09/02/23 203-2 ALINSUB, 68/F INFECTED FOOT, INFECTED WOUND CALCANEAL AREA - RIGHT TYPE 2 DR. LACORDA (PC) A PNSS 1L @ 80 CC/HR SURG/IM
TERESITA RIGHT DIABETES MELLITUS – UNCONTROLLED HYPERTENSION
STAGE II CKD SEC TO DKD AND HKD STAGE 3B ANEMIA DR. MABUNGA D DD
SECONDARY TO CHRONIC DISEASE AND INFLAMMATION (ANES)
M VSQ4, I&O QS, CBG TID PRE MEALS
DR. PANUDA
I PIP TAZO D3, CLINDAMYCIN D3
9/5 (CP & CM)
U 1.0 CPK (50 KG)
ASCENDING FASCIITIS DR. DELES
M
T2DM POORLY CONTROLLED (CP & CM)
1. KETOANALOGUE 2 TABS TID
S/P BKA
2. PIPTAZO 4.5 GMS IV Q6H
HCVD, HF PEF
3. CLINDAMYCIN 600 MG IV Q8H

4. NORGESIC FORTE 1 TAB TID

5. PREGABALIN 75 MG 1 CAP OD AT HS

6. KCL TAB 2 TABS TID X 6 DOSES

7. GIVE ½ VIAL D50-50 FOR CBG <80MG/DL

8. GIVE 4 UNITS RI SQ FOR CBG >180 MG/DL

L 9/5
 U 9/5

FOR AV DUPLEX SCAN

REPEAT K

09/05/23 204-1 OCIONES, 60/M EPIGASTRIC CHRONIC CALCULOUS CHOLECYSTITIS DR. D. A IVR PLR AT 100 CC/HR SURG/IM
MILAGROS PAIN BUENAVENTURA
(PC) D LOW FAT DIET/DAT

DR. J. CRUZ (CM) M VSQ4, I&O QS

DR. MOSQUEDA I
(CM)
U 0.7 CPK (60 KG)
DR. M GONZAGA
(ANES) M

DR. R OMBAO (CP) 5. OMEPRAZOLE 40 MG IV OD ONCE ON NPO

6. PARACETAMOL 300 MG IV Q6 PRN FOR

FEVER

7. BUSCOPAN 10 MG IV Q8 PRN

8. UNASYN 1.5 GRAMS IV THEN 75- MG IV

Q8

L: 9/5

NA 143.4, K 3.16, MG 0.81, CA 1.13, ALK PO4 90

APTT 29, CTRL 31, PT 12.7, INR 1.08 CTRL 13

DB 6.5, IB 14.2, TB 20.7

SGPT 11

U: 9/5

FOR POSSIBLE LAPAROSCOPIC CHOLECYSTECTOMY

SCHEDULE TO FOLLOW
09/04/23 204-3 CAPEDING, 72/F INFRAUMBILICA TO CONSIDER TUOOVARIAN ABSCESS RECURRENCE WITH DR. ENOJO (PC) A PLR 1L @ 90 CC/HR SURG/IM
DELILAH L MASS VESICOCUTANEOUS FISTULA FORMATION
DR. OMBAO (CM) D DD
STATUS POST VAGINAL HYSTERECTOMY (2017)
DR. LLANES (CM) M VSQ4, I&O QS, CBG TID
STATUS POST EXPLORATORY LAPAROTOMY FOR OVARIAN
ABSCESS (2021) I CEFTRIAXONE D1

U 1.8 CPK (48KG)

9/5 M

ABDOMINOPELVIC MASS T/C ABSCESS WITH POSSIBLE 1. SITAGLIPTIN 50 MG 1 TAB BID

VESICOCUTANEOUS FISTULA: PYOGENIC VS TB
2. GLICLAZIDE (DIAMICRON 60 MG 1 TAB OD
HUD

3. AMLODIPINE 5 MG 1 TAB OD

4. METHIMAZOLE (TAPDIN ) 5MG ½ TAB OD

5. BILASTINE 20 MG 1 TAB OD

6. OMEPRAZOLE 40 MG IVTT ONCE ON NPO

7. INSULIN GLARGINE 12 UNITS SQ OD

8. RI 4 UNITS SQ TID PRE MEALS

9. CEFTRIAXONE 2 GM IV OD

10. METRONIDAZOLE 500 MG IV Q8

11. HEMARATE 1 CAP

L 9/5

FT4 1.43, TSH 0.789

HBA1C 7.2

NA 134.7, K 3.57, CA 1.13, MG 0.80

CREA 60, ALB 35

WBC 15.6, RBC 3.7, PLT 428, N 0.77, L 0.14, M 0.05, E

0.03, B 0.00

U 9/5
 FOR CT SCAN

FOLLOW UP WOUND GSCS COLLECTED AS OUTPATIENT

08/27/23 205 ASUNCION, 74/M HEADACHE ACUTE OTOMASTOIDITIS WITH EXTENSION INTO THE DR. LEGITA (PC) A PNSS 1L @ 90 CC/HR SURG/IM
ROMUALDO SURROUNDING SOFT TISSUE OF THE PARAPHARYNGEAL,
MASTICATOR, CAROTID SPACE, RIGHT TO CONSIDER DR. TORNO (CM) D NGT FEEDING: DIABETIC DIET 1700 KCAL IN 6 DIVIDED
OSTEOMYELITIS CHRONIC ISCHEMIC INFARCT, PONS; TYPE 2 FEEDINGS
DM NON INSULIN REQUIRING DR. ANUTA (CM)
M VSQ4, I&O QS, CBG TID
DR. F. HO (CM)
I CEFEPIME D7, LINEZOLID D4
9/5 DR. GONZALES-SY
U 2.0 CPK (65 KG)
ACUTE OTOMASTOIDITIS, RIGHT (EVAL)
M
MASTOIDITIS LEFT,
1. CEFEPIME 1G Q8HRS
CHRONIC PONTINE ISCHEMIC INFARCT
2. CALMAG TAB BID
TYPE 2 DM - NIR
3. GLUSOL’N 18U SQ3HS

4. R1 18 U PRE FEEDING/MEALS

5. R1 10 U PRE FEEDING/MEALS

6. R1 14U PRE MEALS

7. AMLODIPINE 10MG 1 TAB OD

8. LOSARTAN 100MG/TAB 1 TAB OD

9. FLUCONAZOLE 200 MG I 1 CAP OD

10. OTIC DROPS TID

11. CITICHOLINEÑGM 1 TAB TID

12. LINEZOLID 600MG IV Q12H

13. NAC 600 MG/TAB 1 TAB OD AT HS

14. PANTOPRAZOLE 40 MG IV OD

15. LACTULOSE. 30CC OD AT HS

L: 9/5

U: 9/5

FOR MODIFIED RADICAL MASTOIDECTOMY RIGHT

 FOR TRANSFER TO SPH

09/04/23 207 TORMIS, 69/M HEMATURIA HEMORRHAGIC CYSTITIS DR. ENOJO (PC) A PLR 1L @ 100 CC/HR SURG/IM
ROLANDO
URINARY RETENTION SECONDARY TO ENLARGED PROSTATE DR. LINDO (ANES) D LSLF

R/O MALIGNANCY DR. MAGNO (CM) M VSQ4, I&O QS

I CEFTRIAXONE D0

9/5 U 0.9 CPK (56 KG)

HEMORRHAGIC CYSTITIS M

URINARY RETENTION SECONDARY TO ENLARGED PROSTATE 1. CEFTRIAXONE 2 GM IV NOW THEN OD

ANST
R/O MALIGNANCY
2. TAMSULOSIN 400 MCG 1 TAB OD HS
HPN II
3. TRAMADOL + PARACETAMOL 1 TAB TID

4. SOLIFENACIN SUCCINATE 5 MG 1 TAB BID

L 9/5

PSA 9.50

U 9/5

FOR CYSTO TURP ON WEDNESDAY T/F 1ST CASE

08/10/23 209 FAISAL, 25/M SOFT TISSUE SOFT TISSUE INJURY, LEFT LATERAL DR. YAMBAO-ARAO A: NO IVF IM/SURG
MUHADJER INJURY (PC)
MALLEOLUS, TO CONSIDER MULTIPLE FRACTURES SECONDARY D: DAT + EGG WHITES (STRICT ASPIRATION PRECAUTION)
TO MOTOR VEHICULAR ACCIDENT DR. MABUNGA ISLAM
(ANESTH)
M: VSQ4, I&O QS
DR. K. ROA (CM)
FINAL DIAGNOSIS I:
DR. K LIM (PLASTICS
OPEN ANKLE INJURY WITH AVULSED WOUND LATERAL ASPECT - CO MGT) U: 1.6 CPK(56 KG)
LEFT ANKLE CLOSED
DR. LACORDA (TSP) M:
FRACTURE MEDIAL MALLEOLUS LEFT ANKLE SECONDARY TO
ROAD TRAFFIC ACCIDENT 1. NORGESIC FORTE 1 TAB Q8

L: 9/5
 U: 9/5

MGHSI

09/02/23 210 YONSON, 67/M DYSURIA BLADDER OUTLET OBSTRUCTION SECONDARY TO BLEEDING DR. ENOJO (PC) A PLR 1L @ 100 CC/HR SURG/IM
ELEUTERIO URINARY BLADDER TUMOR VS PROSTATOMEGALY
DR. KASILAG (CM) D LSLF
HYPERTENSION STAGE 2
M VSQ4, I&O QS

I CEFTRIAXONE D2
9/5
U 1.2 CPK (76 KG)
BLADDER OUTLET OBSTRUCTION SECONDARY TO BLEEDING
URINARY BLADDER TUMOR VS PROSTATOMEGALY M

HYPERTENSION STAGE 2 1. TRANEXAMIC ACID 500 MG IV Q8

2. CEFTRIAXONE 2 GM IV OD

3. AMLODIPINE 5 MG OD

4. LOSARTAN 50 MG OD

5. KCL TABLET TID

L 9/5

U 9/5

S/P CYSTO TURP

FOR CBC, CREA, NA, K, MG, CA TOMORROW 6 AM

08/31/23 212 SAHIDHID, 45/M NON HEALING NON HEALING WOUND LEFT LOWER LEG DR. LOPEZ (PC) A PNSS 1L @ 80CC/HR SURG/IM
TIMOTEO WOUND
DR. E. GARCIA D DD, +2 EGG WHITES/ MEAL
(ANES)
FINAL DIAGNOSIS M VSQ4, I&O QS, CBG O2
DR. RAMITERRE
INFECTED WOUND SECONDARY TO CELLULITIS POSTERIOR I
LEG, LEFT (CP & CM)
U 1.4 CPK (105 KG)

1. CO-AMOXICLAV 625MG 1 TAB BID X 7

DAYS D 0+1

2. CILOSTAZOL 100 MG TAB OD

3. METFORMIN 500 MG TAB BID

L 9/5

WOUND CS NO GROWTH AFTER 48 HOURS OF

INCUBATION

U 9/5

MGHSI

09/01/23 214 DOMINGO, 74/M HEMATURIA URINARY OUTLET OBSTRUCTION PROBABLY SECONDARY DR. DELA VICTORIA A: D5LR 1L @ 100 CC/HR SURG/IM
TIRSO MALIGNANT PATHOLOGY (PC)
PNSS 1L @ 100 OR KVO CC/HR
HYPERTENSIVE CARDIOVASCULAR DISEASE, CORONARY DR. MAGLANA (CM)
ARTERY DISSEASE D: DAT + 2 EGG WHITES
DR. GALLEMASO
S/P PACEMAKER INSERTION (CM) M: VSQ4, I&O Q4,

DR. ROA (EVAL) I: BACTIV D4

9/5 U: 0.19 CPK (63 KG)

URINARY OUTLET OBSTRUCTION PROBABLY SECONDARY TO M:

MALIGNANT PATHOLOGY
1. BACTIV 1.2 GM IVTT Q12H AT REF
HCVD, CAD
2. HEMOSTAN 500 MG TID PO
S/P PACEMAKER INSERTION
3. PARACETAMOL 500 MG TAB Q4H RTC
 4. STRESSTABS 1 TAB TID

5. ALENDRONIC ACID 700 MG TAB 1 TAB

ONCE A WEEK

6. DOLCET 1TAB TID X 1 WEEK

7. LIPITOR 40MG OD AT HS

8. AMLODIPINE + LOSARTAN 100/10 MG 1

TAB OD

L: 9/5

X RAY UNREMARKABLE PULMONARY FINDINGS

LEFT VENTRICULAR CARDIOMEGALY

ATHEROMATOUS AORTA

PSA 6.61

NA 140.3, K 3.69, MG 0.65, CA 1.24, CREA 78

U: 9/5

FOR URINE CULTURE

FOR X RAY THORACOLUMBAR APL

08/14/23 216 MICLAT, 59/M ABDOMINAL TO CONSIDER ACUTE APPENDICITIS VS. ACUTE DR. JAMIANA (PC) A NO IVF SURG/IM
ROBERTO PAIN CHOLECYSTITIS
DR. ENOJO (CM) D DAT

DR. BANZON (ANES) M VSQ4, I&O QS, O2 2 LPM PRN

FINAL DIAGNOSIS
DR. J CRUZ (CM) I
ACUTE ABDOMEN SECONDARY TO PERFORATED PEPTIC
ULCER DISEASE; RENAL MASS LEFT DR. LU (CM) U 1.08 CPK (67 KG)

ANEMIA SECONDARY TO RETROPERITONEAL HEMATOMA DR. QUIBO M

SECONDARY TO BLEEDING RENAL MASS LEFT PROBABLY
RENAL CELL CARCINOMA (CM & CP) 1. NAHCO3 650MG/ TAB 1 TAB TID

HYPOVOLEMIC SHOCK SECONDARY TO ACUTE BLOOD LOSS DR. PUNAY (CM) 2. KETOANALOGUE 1 TAB TID
SECONDARY TO BLEEDING RENAL MASS, LEFT
DR. VEGA-BUNO 3. CARVEDILOL 6.25MG 1 TAB BID
PLEURAL EFFUSION RIGHT PROBABLY PARAPNEUMONIC IN (EVAL)
4. COLCHICINE 1 TAB BID
ORIGIN ON TOP OF CONGESTION SECONDARY TO ACUTE
DECOMPENSATED HEART FAILURE
 ACUTE KIDNEY INJURY SECONDARY TO RENAL 5. PARACETAMOL 650 MG 1 TAB TID
HYPOPERFUSION ON TOP OF INFECTION AND ANEMIA
SEVERE 6. ACUFLAM SPRAY APPLY TO AFFECTED
AREA TID

7. FEBUXOSTAT 40MG TAB 1 TAB OD W/ BF

L 9/5

U 9/5

MGHSI

EXECUTIVE WING: 7

DATE RM PATIENT’S AGE / CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON REMARKS SERVICE
ADMITTE NAME SEX COMPLAINT FOR S
D REFERRA
L

09/05/23 226 BULLANDAY, 48/F DYSURIA PARTIAL INTESTINAL OBSTRUCTION SECONDARY TO RECTAL DR. OTERO (PC) A D5LR 1L @ 100 CC/HR IM
CELESTINA CARCINOMA R/O URINARY BLADDER INFILTRATES HYPERTENSION
STAGE 2 DR. MATUNOG (CM) D SOFT DIET

M VSQ4, I&O QS

U CPK (40 KG)

1. SULTAMICILLIN 1.5 GM IV Q6

2. BISOPROLOL 5 MG 1 TAB OD

L 9/5

WBC 10, RBC 4.0, HGB 9.3, HCT 0.32, PLT 402, N 0.67, L 0.21,
M 0.08, E 0.04, B 0.00

ALB 39

U 9/5
 FOR WA CT SCAN WITH CONTRAST TOMORROW 1 PM

08/22/23 227 PADILLA, 58/M RESTLESSNESS UREMIC ENCEPHALOPATHY SECONDARY TO ESRD SECONDARY TO DR. VILLANUEVA (PC) A PNSS 1L @ 10 CC/HR IM
ELORDE HYPERTENSIVE NEPHROSCLEROSIS
DR. YBAÑEZ (CM) D5NSS 1L @ 80 CC/HR
HYPERTENSION STAGE 2
DR. ALCASID (CM) D LSLF, SOFT DIET WITH SAP
GOUTY ARTHRITIS NOT IN FLARE
DR. MANSILLA (TSP) M VSQ4, I&O QS, CBG TID, O2 3 LPM/NC

DR. BANGOY I
9/5
(TUBE U 0.6 CPK (44 KG)
SHOCK CARDIOGENIC ON TOP OF SEPTIC ENCEPH SECONDARY TO CHOLECYSTOMY)
CRBSI M
DR. ABOUZAKI (CM)
MODERATE CHOLECYSTITIS 1. FEBUXOSTAT 40 MG 1 TAB OD
DR. M VILLANUEVA
ESRD SEC. TO HPNNS (SURG CONSULT) 2. PANTOPRAZOLE 40 MG 1 TAB OD

HF WITH EF 40% DR. CRUZ (ERCP) 3. BISOPROLOL 5 MG 1 TAB OD

DR. BERNOLO (ANES) 4. ALDACTONE 25 MG 1 TAB OD

DR. FUENTES (ANES) 5. EMPAGLIFLOZIN 10 MG 1 TAB OD

DR. ABDURAHMAN 6. ENTRESTO 100 MG 1 TAB IN AM

(CP)
7. ENTRESTO 50 MG 1 TAB IN PM

8. NAHCO3 650 MG 1 TAB TID

9. VIT. K 1 AMP IV Q12

10. CALVIT 1 TAB TID

11. TRANSMETIL 1 CAP TID

12. DOLCET 1 TAB Q8 X 1 DAY

13. SEVELAMER 800 MG 1 TAB TID

14. LACTULOSE (LILAC) 20 CC OD HS (HOLD IF BM >3X)

15. RISPERIDONE 2 MG 1 TAB OD HS

L 9/5

DB 15.4, IB 11.8, TB 27.2

ALK PO4 258

2D ECHO ECCENTRIC LEFT VENTRICULAR HYPERTROPHY WITH

GLOBAL HYPOKINESIA. OVERALL SYSTOLIC FUNCTION IS
REDUCED WITH MODERATE DIASTOLIC FUNCTION. SEVERE
 MITRAL AND TRICUSPID REGURGITATION.

U 9/5

08/14/23 228 MONDAY, 48/F DECREASED SECONDARY HEADACHE PROBABLY SECONDARY TO SPACE DR. YBAÑEZ (PC) A NO IVF IM
PANCHITA SENSORIUM OCCUPYING LESION
DR. J. TORRES (CM) D SD, DD, LSLF, NO CHICKEN
T/C CENTRAL VENOUS SINUS THROMBOSIS
DR. ONGKINGCO M VSQ4, I&O QS
HPN STAGE 2 (EVAL)
I
DR. VALLES (TSP)
U 1.0 CPK (72 KG)
FINAL DIAGNOSIS DR. DY. K (EVAL)
M
INTRACRANIAL, EXTRA-AXIAL MASS LESION, PARASAGITTAL DR. LAGAPA (CM)
BIFRONTAL MENINGIOMA WITH POSSIBLE SAGITTAL SIMS 1. LOSARTAN 100 MG 1 TAB OD
COMPRESSION; TYPE 2 DIABETES MELLITUS WITH STEROID INDUCED DR. BAGIS (EVAL)
HYPERGLYCEMIA;HYPERTENSION STAGE II 2. HEMARATE FA 1 TAB OD
DR. MADAYAG (REHAB)
3. ATORVASTATIN 40MG 1 TAB ODHS

4. SITAGLIPTIN 100 MG 1 TAB OD

5. LEVETIRACETAM 1G 1 TAB BID

6. GLARGINE 24 U SC ODHS

7. METFORMIN 500MG 1 TAB BID

8. AMLODIPINE 10 MG 1 TAB OD

L 9/5

U 9/5

MGHSI
08/30/23 229 ALIAN, DIANA 84/F DYSPNEA CARDIOGENIC SHOCK SECONDARY ACUTE DECOMPENSATED HEAR DR. ARSOLON (PC) A PNSS 1L @ 10 CC/HR IM
FAILURE
DR. MAGALLANES (CM) SD: FURO 100 MG + 100 PNSS @ 10 CC/HR
HYPERTENSIVE CARDIOVASCULAR DISEASE
DR. YARRA (IJ CATH) D ENSURE 1400 KCAL IN 6 DIVIDED FEEDINGS
CHRONIC KIDNEY DISEASE SECONDARY TO HYPERTENSIVE KIDNEY
DISEASE DR. YBAÑEZ (TOS) M VSQ1, NVSQ, I&O Q1, O2 MECHVENT, CBG Q6

S/P CP ARREST DR. BRAVO (PALLIA) I MEROPENEM D0

DR. ARSOLON (CM) U 1.5 CPK (50 KG)

9/5 DR. TORRES (CM) M

SEIZURES SECONDARY TO HIE DR. JAMIANA (OFF) 1. CLOPIDOGREL 75 MG 1 TAB OD

ADHF 2. KETOANALOGUE (AMINOLOG) 2 TABS TID

AKI SECONDARY TO HKD 3. TRIMAG 1 TAB TID

4. LEVETIRACETAM 100MG/5ML 7.5 ML NGT BID

5. VALPROIC ACID (DEPAKENE) 250MG/5ML 10 ML

Q8

6. LACOSAMIDE 100 MG 1 TAB BID

7. NAC 600 MG IN ½ GLASS WATER OD HS

8. PERAMPANEL 4 MG 1 TAB OD HS

9. ATORVASTATIN 40 MG 1 TAB OD HA

10. SALBUTAMOL IPRATROPIUM NEB Q8

11. CLONAZEPAM 2 MG ¼ TAB TID

12. MEROPENEM 500 MG IV Q12

L 9/5

CXR PA: PROGRESSING BILATERAL PNEUMONIA WITH

RECENT BILATERAL MINIMAL PLEURAL EFFUSION.
INTERCURRENT PULMANORY EDEMA CONSIDERED. LEFT
VENTRICULAR CARDIOMEGALY. ATHEROMATOUS AORTA.
PLEURODIAPHGRAGMATIC ADHESION- RIGHT NOT
APPRECIATED IN PRESENT STUDY

U 9/5

DNI/DNR
09/01/23 230 MAGNO, 86/F UNRESPONSIV T/C SEPTIC VS METABOLIC ENCEPHALOPATHY DR. ABOUZAKI (PC) A: PNSS @ 400 CC/HR IM
ALICIA E
HYPERTENSIVE CARDIOVASCULAR DISEASE, LVH, HEART FAILURE DR. ARSOLON (CM) D: GLUCERNA FEEDING 1800 KCAL IN 6 DIVIDED FEEDINGS
WITH PRESERVED EJECTION FRACTION
DR. CABAHUG (CM) M: VS Q1, I&O Q1
CHRONIC KIDNEY DISEASE SECONDARY TO HYPERTENSIVE KIDNEY
DISEASE / DIABETIC KIDNEY DISEASE DR. AYCO (CM) I: MEROPENEM D1

S/P CVA 1998 WITH RESIDUAL LEFT SIDED WEAKNESS DR. VEGA-BUNO (AMS) U: 0.6 CPK (65 KG)

DEMENTIA FEB 2023 M:

1. MEROPENEM 500 MG IV Q12

9/5 2. FESO4 + FA 1 TAB OD

AKI SECONDARY TO INFECTION ON TOP OF CKD SECONDARY TO 3. RABEPRAZOLE 20 MG 1 TAB OD

HKD/DKD
4. ASPIRIN 80 MG 1 TAB OD
T/C SEPTIC ENCEPHALOPATHY
5. NAHCO3 650 MG 1 TAB TID
HF REF
6. KETOANALOGUES + AMINO ACIDS 600 MG 1
DEMENTIA TAB TID

7. KCL 1 TAB TID X 12 DOSES

8. LEVETIRACETAM 1 GM 1 TAB Q12

9. ROSUVASTATIN 20 MG 1 TAB ODHS

10. IPRATROPIUM NEB O6

11. ISMN 30 MG TAB BID

12. TRIMAG CAP BID

L: 9/5

U: 9/5

DNR/DNI

HOLD EEG

FOR CARDIOEMBOLIC STOCKINGS

08/26/23 231 GUERTA, 52/M LEFT SIDED INTRACEREBRAL HEMORRHAGE RIGHT DR. LAGAPA (PC) A: PNSS 1L @ 10 CC/HR SURG/
TEODORO WEAKNESS
HYPERTENSIVE CARDIOVASCULAR DISEASE DR. ABOUZAKI (CM) STEROFUNDIN 1L @ 70 CC/HR IM

DR. BARINAGA (ANES) D: ENSURE 1800 KCAL/ DAY IN 1:1 DILUTION Q3 IN 7 DIVIDED
FEEDINGS BANANA BASED (6AP-9AP-12AP-3P) 250 CC
FINAL DIAGNOSIS DR. ORCASITAS (CM)
M: VSQ4, I&O QS, O2 1 LPM/NC
RIGHT CAPSULOGANGLIONIC HYPERTENSIVE BLEED DR. PUNAY (TSP)
I:
S/P RIGHT FRONTOTEMPORAL CRANIOTOMY; EVACUATION OF BLEED DR. HERRERA (REHAB)
U: 1.8 CPK (98 KG)

M:

1. TELMISARTAN 80 MG 1 TAB OD

2. AMLODIPINE 10 MG 1 TAB OD

3. DOMPERIDONE + PANTOPRAZOLE PRE BFAST OD

4. EDARAVONE 30MG IN 30CC PNSS TO RUN FOR 30

MINS Q12

5. LEVETIRACETAM 5ML SYRUP Q12

6. CARVEDILOL 25 MG 1 TAB BID

7. CITICOLINE 1 GM TAB 1 TAB BID

8. NAC 600MG TAB 1 GLASS OF H20 BID

9. CEREBROLYSIN 10CC IV BOLUS Q8

10. CLONIDINE 150 MCG TAB Q8

11. REBAMIPIDE 100 MG/TAB 1 TAB TID

12. CHLORHEXIDINE (ORAL CARE) TID

13. MUPIROCIN OINTMENT APPLY ON INCISION SITE

OD

14. ROSUVASTATIN 40 MG 1 TAB ODHS

15. ISMN 30 MG 1 TAB ODHS

16. SALBUTAMOL NEB +2CC PNSS 66 HRS NORGESIC

FORTE 1 TAB Q8 RTC

17. RACECADOTRIL 100 MG 1 CAP TID

18. SALBUTAMOL NEB + 2 CC PNSS Q8

 L: 9/5

U: 9/5

FOR 2D ECHO TODAY

FF UP OFFICIAL 2D ECHO RESULTS

FOR REASSESSMENT OF GAS AS OPD

FOR CRANIAL CT SCAN

FACILITATE SPUTUM GSCS

MAY FEED WITH ASPIRATION PRECAUTION

CONTINUE REHAB

08/22/23 233 ASERIOS, 67/M DYSPNEA ACS ANTEROSEPTAL WALL STEMI KILLIPS III DR. COCHING (PC) A: NO IVF IM
ROMEO
CAP HR (HYPOXEMIA); RULE OUT METASTATIC PROCESS DR. B. CHIEW (TSP) D: LSLF (PLANT BASED) ALLERGIC TO SEAFOOD

AKI PROBABLY SECONDARY TO INFECTION DR. ORCASITAS (CM) M: VSQ4, I&O QS

ON TOP OF CKD SECONDARY TO DKD AND HPNSS WITH RENAL ANEMIA DR. TOM (CM) I:

HCVD, SR, IHD, HF REF (40%) DR. PUNAY (TSP) U: 0.9 CPK (65 KG)

T2DM NIR M:

MEI (HYPOKALEMIA, HYPOCALCEMIA, HYPONATREMIA ) 1. SPIRONOLACTONE 25 MG 1 TAB OD

2. ASPIRIN 80 MG 1 TAB OD

FINAL DIAGNOSIS 3. ZANDIP 10 MG 1 TAB OD

ACUTE RESPIRATORY FAILURE TYPE 1 SEC TO PULMONARY 4. CLOPIDOGREL 75 MG 1 TAB OD

CONGESTION SEC TO ACUTE CORONARY SYNDROME STEMI KILLIP III
WITH MODERATELY REDUCED EJECTION FRACTION (49%) 5. PANTOPRAZOLE 40 MG 1 CAP OD

ACUTE KIDNEY INJURY SEC TO INFECTION ON TOP OF CHRONIC KIDNEY 6. EMPAGLIFLOZIN 25 MG ½ TAB OD
DISEASE HYPERTENSIVE NEPHROSCLEROSIS
7. GLICLAZIDE 60 MG 1 TAB OD
HYPERTENSIVE CARDIOVASCULAR DISEASE, ISCHEMIC HEART DISEASE
8. CONCOR 2.5 MG 1 TAB OD
TYPE 2 DM
9. ALLOPURINOL 300 MG 1 TAB OD

10. LEVOPRONT 10 ML TID

11. SODIUM BICARBONATE 650 MG 1 TAB TID

12. EPO ALPHA 4,000 IU SC ONCE A WEEK

 13. FUROSEMIDE 20 MG 1 TAB OD

14. FERROUS FUMARATE 1 TAB OD

15. ROSUVASTATIN 20MG 1 TAB ODHS

L: 9/5

U: 9/5

MGHSI

ICU: 2

DATE RM PATIENT’S NAME AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FOR REMARKS SERVICES
ADMITTED SEX COMPLAINT REFERRAL
09/04/23 ICU-3 CONCEPCION, 46/M DYSPNEA PULMONARY CONGESTION PROBABLY SECONDARY TO HEART DR. BONJE (PC) A LEFT: PNSS 1L @ 5 CC/HR IM
DEXTER FAILURE
DR. ELORDE RIGHT: PNSS 1L @ 10 CC/HR
COMMUNITY ACQUIRED PNEUMONIA – HIGH RISK (CM)
SD: PNSS 100 CC + 40 MEQS KCL @ 20/HR X 3 CYCLES
T/C CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN ACUTE DR. FADERAN
EXACERBATION (CM) D LSLF (DM DIET)

AKI SECONDARY TO INFECTION ON TOP OF CKD SEC TO DKD/ DR. M VSQ1, NVSQ1, I&O Q1
HKD DILANGALEN
(TSP) I
ANEMIA (MULTIFACTORIAL) SEC TO INFLAMMATION / CKD
DR. LEE (AMS) U 2.9 CPK (75 KG)
MULTIPLE ELECTROLYTES IMBALANCE
DR. FRANCO M
HYPERTENSIVE CARDIOVASCULAR DISEASE (TSP)
1. SALBUTAMOL + IPRA NEB Q6 + 2 CC PNSS
TYPE 2 DIABETES MELLITUS – INSULIN REQUIRING
2. FENOFIBRATE (LIPWAY) 160 MG 1 TAB OD
S/P CVA 2021 WITH LEFT SIDED RESIDUAL WEAKNESS
3. ATORVASTATIN (LIPITOR) 80MG 1 TAB OD
S/P BKA LEFT
4. ALPHA LIPOIC ACID 600 MG 1 TAB OD

5. BENFOTIAMINE + METHYLCOBALAMIN (NEUROPAT)

9/5 100/150/100 MG 1 TAB OD

ACS NSTEMI, KILLIPS III 6. NEUROAID II 1 TAB OD

HCVD, LVH, SR 7. CITICOLINE 1 GRAM 1 TAB BID

HF MREF (47%), CAD 8. AMLODIPINE VALSARTAN 5/80 MG 1 TAB OD

HYPERACTIVE AIRWAY DISEASE, T/C COPD 9. CLONIDINE (CLONIGEN) 75 MG 1 TAB OD

 CAP HR 10. CLOPIDOGREL 75 MG 1 TAB OD

T2DM IR 11. MEROPENEM 1 GRAM IV Q12 D2

AKI SECONDARY TO INFECTION ON TOP OF CKD FROM DKD, 12. CALMAG 1 TAB TID
HKD
13. HYDROCORTISONE 100MG IV 98

14. ENOXAPARIN 0.6 CC SO OD D Y

15. ASPIRIN 80 MG 1 TAB OD

16. PANTOPRAZOLE 40 MG 1 CAPSULE OD AC

17. SENOKOT FORTE 1 TAB OD AT HS

18. NAHCO3 650MG 1 TAB TID

19. KETOANALOGUE 2 TABS TID

20. PARACETAMOL 300MG IV Q4 RTC X 3 DOSES (THEN, PRN

FOR FEVER)

21. FUROSEMIDE 40 MG IV 98

22. BISOPROLOL 5MG OD

23. ISMN 30MG TAB OD HS

24. KCL 2 TABS TID X4 DAYS

25. INSULIN 70/30 INSUGET (HOLD INSULIN 70/30 INSUGET IF

CBG < 140)

28 UNITS SQ PRE BREAKFAST

14 UNITS SO PRE LUNCH

10 UNITS SQ PRE DINNER

L 9/5

K 3.29, MG 1.05

ALB 33, SGPT 30

U 9/5

FF UP 2D ECHO RESULTS

09/05/23 ICU-8 CATIPAY, 39/M BODY ACUTE RESPIRATORY FAILURE TYPE 2 SECONDARY TO DR. D A PNSS 1L @ 180 CC/HR IM
RICHARD MALAISE OBSTRUCTIVE SLEEP APNEA HYPOPNEA SYNDROME BERNARDO (PC)
 HYPERTENSION STAGE 2 DR. D START ENSURE 1800 KCAL/DAY IN 6 DIVIDED FEEDINGS
MAGALLANES
ACUTE KIDNEY INJURY ON TOP OF POSSIBLE CHRONIC KIDNEY (CM) M VSQ1, NVSQ1, I&O Q1, O2 MECHVENT
DISEASE SECONDARY TO HYPERTENSIVE NEPHROSCLEROSIS
I PIP TAZO D0
GOUTY ARTHRITIS NOT IN FLARE
U CPK (62 KG)

1. PIPERACILLIN + TAZOBACTAM 4.5 GRAMS 2.25 GRAMS IV

Q6

2. AMLODIPINE + VALSARTAN + HCTZ 5/160/25 MG TAB OD

3. ALLOPURINOL 100 MG TAB OD

L 9/5

CXR: LEFT SIDED CARDIOMEGALY WITH PULMONARY CONGESTION.

CONCURRENT PNEUMONIA CONSIDERED

ATHEROMATOUS AORTA

THORACIC DEGENERATIVE OSTEOARTHROPATHY

TROP I 0.13

CREA 369 EGFR 18, SUA 850, SGPT 27

WBC 17.5, RBC 6.4, HGB 17.6, HCT 0.60, PLT 219, N 0.74, L 0.16, M
0.07, E 0.02, B 0.01

NA 141, K 5.20 H, CA 1.17

U 9/5

FEMALE SERVICE WARD: 2

DATE RM PATIENT’S NAME AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FOR REMARKS SERVICES
ADMITTED SEX COMPLAINT REFERRAL
08/24/23 235-1 PISIAO, 51/F COUGH HYPERTENSIVE URGENCY DR. ANUTA (PC) A PNSS 1L @ 80 CC/HR SURG/
IM
LILIA DR. M HERRERA D DAT + 1 BANANA/MEAL
(CM)
FINAL DIAGNOSIS M VSQ4, I&O QS, CBG BID, O2 PRN
DR. FLORESCA
ACUTE CEREBROVASCULAR ACCIDENT RIGHT MIDDLE CEREBRAL (TSP) I
ARTERY
U 1.1 CPK (54 KG)
HOSPITAL ACQUIRED PNEUMONIA
M
ASYMPTOMATIC HYPERURICEMIA
1. FEBUXOSTAT 40 MG TAB OD

2. ATORVASTATIN 80 MG TAB OD

3. CITICOLINE 1 GM IVTT

4. CLOPIDOGREL 75 MG TAB OD

5. PANTOPRAZOLE 40 MG TAB OD

6. NEUROAID 1 CAP BID

7. KCL 2 TABS BID X 7 DOSES

8. CILOSTAZOL 50 MG TAB BID

9. AMLODIPINE 10 MG 1 TAB OD

L 9/5

U 9/5

MGH

08/18/23 235-4 PEPANIA, 73/F DIZZINESS HYPERTENSIVE URGENCY DR. MAGNO A: NO IVF IM
ESTERLITA (PC)
TYPE 2 DM NON INSULIN REQUIRING D: BANANA BASED W/ GLUCERNA 1800 KCAL IN 6 DIVIDED FEEDINGS
DR. LEGITA (CM) WITH SAP (300 CC)
TO CONSIDER COMPLICATED UTI
DR. HERRERA M: VSQ4, I&O QS
(REHAB)
I:
FINAL DIAGNOSIS
U: 0.4 CPK (54 KG)
ACUTE CEREBROVASCULAR INFARCT - RIGHT MIDDLE CEREBRAL
ARTERY M:

TYPE 2 DIABETES MELLITUS - INSULIN DEPENDENT 1. GLYXAMBI 25/5 MG 1 TAB OD

 HYPERTENSION STAGE 2 2. PLETAAL SR 200 MG 1 TAB OD

3. NAC 600 MG 1 TAB OD HS

4. CITICOLINE 1 GM 1 TAB BID

5. AMLODIPINE 10 MG 1 TABLET OD

6. ATORVASTATIN 40 MG 1 TAB OD @ HS

7. OMEPRAZOLE 90 MG 1 CAP OD PRE BT

8. HUMULIN 70/30 40 U PRE BF

20 U PRE DINNER

PRN MEDICATIONS

1. RI 4 U FOR CBG > 180 MG/DL

2. CLONIDINE 75 MG 1 TAB SL PRN SBP > 160

3. NORGESIC FORTE 1 TAB TID PRN

4. BETAHISTINE 24 MG FOR 1 TAB PRN DIZZINESS

5. CINNARIZINE 75 MG 1 TAB OD PRN

6. NORGESIC FORTE 1 TAB TID PRN

L: 9/5

U: 9/5

MGHSI

DELIVERY ROOM/LABOR ROOM: 0

DATE RM PATIENT’S NAME AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FOR REMARKS SERVICES
ADMITTED SEX COMPLAINT REFERRAL

OBGYNE WING: 0

DATE RM PATIENT’S AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON REMARKS SERVICES
ADMITTED NAME SEX COMPLAIN FOR
 T REFERRAL

DISCHARGED: 10

DATE RM PATIENT’S AGE/ SEX CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FINAL DIAGNOSIS SERVICE
ADMITTED/ NAME COMPLAINT FOR S
DISCHARGED REFERRAL

08/28/23 201- MANLIGOY, 47/M NASAL NASAL POLYP LEFT DR. LLAMERA (PC) BILATERAL NASAL POLYPOSIS WITH PANSINUSITIS SURG/
1 CLOYD CONGESTION IM
HYPERTENSION STAGE II DR. VILLAROSA HYPERTENSION STAGE II
(ANES)
S/P ENDOSCOPIC SURGERY; POLYPECTOMY; ETHMOIDECTOMY, ANTROSTOMY
DR. GUILLERMO BILATERAL
(CP AND CM)

DR. B RAMOS (CP)

09/02/23 220 GONZALES, 61/M FOR COLON CANCER ST IV WITH LIVER AND PULMONARY DR. GALICIA (PC) COLON CANCER STAGE IV IM
CARLOS CHEMOTHER METASTASES
APY
HYPERTENSION STAGE 2

08/30/23 240 MONTAÑO, 36/F BREECH GRAVIDA 2 PARA 1 (1001) PREGNANCY UTERINE 37 1/7 DR. VELIGANIO GRAVIDA 2 PARA 2 (2002) PREGNANCY UTERINE DELIVERED TERM BREECH OB/IM
CARMELA PRESENTATION WEEKS AGE OF GESTATION BREECH IN LATENT PHASE OF (PC) LIVEBIRTH BABY GIRL APGAR 8,9 BIRTHWEIGHT 4610 GRAMS BALLARD SCORE
LABOR; GESTATIONAL DIABETES MELLITUS INSULIN 38 WEEKS LARGE FOR GESTATIONAL AGE VIA PRIMARY LOW SEGMENT
REQUIRING; GESTATIONAL HYPERTENSION; FETAL DR. VELIGANIO TRANSVERSE CESAREAN SECTION SECONDARY TO MALPRESENTATION AND
(ANES)
MACROSOMIA; FETAL MACROSOMIA UNDER SUBARACHNOID BLOCK ANESTHESIA; DIABETES
MELLITUS INSULIN REQUIRING; GESTATIONAL HYPERTENSION; FETAL
DR. LUY (CM)
ADVANCED MATERNAL AGE, POLYHYDRAMNIOS MACROSOMIA; POLYHYDRAMNIOS

09/04/23 220 TANCONTIAN 47/F FOR INVASIVE DUCTAL CARCINOMA STAGE III (T3N1M0), LEFT DR. GALICIA (PC) IM
, MIRIAM CHEMOTHER
APY S/P EXCISION OF BREAST MASS WITH FSB LEFT, MODIFIED
RADICAL MASTECTOMY, LEFT
 FINAL DIAGNOSIS

INVASIVE DUCTAL CARCINOMA STAGE III (T3N1MO);LEFT

09/02/23 201- MATUTE, 61/M HEMATOCHEZIA ANAL MASS, PROBABLY MALIGNANT DR. PURACAN ANAL MASS, PROBABLY MALIGNANT SURG/
6 ALFREDO (PC) IM
ESSENTIAL HYPERTENSION ESSENTIAL HYPERTENSION
DR. BANSON
(ANES)

DR. RASHID (CM)

08/31/23 208 CABACTULA 34/M SWELLING OF CELLULITIS, LEFT LEG DR. BORJE (PC) CELLULITIS, LEFT LEG SURG/
N, DENNIS LEFT FOOT IM
DR. FERRER (CM)

08/31/23 19 BRIONES, 34/F FEVER DENGUE W/ WARNING SIGN R/O RHD DR. MAGNO DENGUE WITH WARNING SIGNS IM
JOSEILEEN

09/01/23 34 TAJOS, 32/M PALLOR 09/05 DR. TOM (PC) UPPER GASTROINTESTINAL BLEEDING SECONDARY TO EROSIVE GASTRITIS, IM
JOSEPH SEVERE ANEMIA SECONDARY TO UPPER GASTROINTESTINAL BLEEDING
ANEMIA SECONDARY TO UGIB ON TOP OF RENAL ESRD CHRONIC KIDNEY DISEASE STAGE 5 SECONDARY TO CHRONIC
SEC TO CHRONIC GLOMERULONEPHRITIS SEC TO GLOMERULONEPHRITIS
HYPERTENSION T/C HYPOPROLIFERATIVE ANEMIA

08/27/23 38 OLEDAN, 70/F DISORIENTATI SEPTIC ENCEPHALOPATHY, SOURCE TO BE DETERMINED DR. RASHID (PC) SEPTIC ENCEPHALOPATHY SECONDARY TO ASPIRATION PNEUMONIA, IM
VIVIEN ON RIGHT;ACUTE KIDNEY INJURY SECONDARY TO INFECTION
HYPERTENSIVE CARDIOVASCULAR DISEASE

TYPE 2 DIABETES MELLITUS NON INSULIN REQUIRING

09/01

SEPTIC ENCEPHALOPATHY SEC TO ASPIRATION

PNEUMONIA

ACUTE KIDNEY INJURY SEC TO SEPSIS

HCVD

T II DM NIR
 08/30/23 226 COLLANTES, 44/M CHEST PAIN ACS NSTEMI PROB SECONDARY TO DRUG RELATED DR. OMBAO ACUTE CORONARY SYNDROME-NON ST ELEVATION IM
VENGIE CARDIOMYOPATHY
(PC) MYOCARDIAL INFARCTION KILLIP I

HEART FAILURE WITH MODERATELY REDUCED EJECTION FRACTION

HYPERTENSIVE CARDIOVASCULAR DISEASE

TRANSFER TO OTHER HOSPITAL: 0

DATE RM PATIENT’S AGE/SEX CHIEF ADMITTING DIAGNOSIS PHYSICIAN TRANSFER TO REASON FOR FINAL DIAGNOSIS SERVICE
ADMITTED NAME COMPLAINT REFERRAL

TRANSFER TO ICU: 0

DATE RM PATIENT’S AGE/SEX CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON REMARKS SERVICES
ADMITTED NAME COMPLAINT FOR
REFERRAL

TRANSOUT FROM ICU TO WARD: 0

DATE RM PATIENT’S AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON REMARKS SERVICES
ADMITTED NAME SEX COMPLAINT FOR
REFERRAL

WARD MORTALITY: 0

DATE RM PATIENT’S AGE/ CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FOR FINAL DIAGNOSIS SERVICES
ADMITTED NAME SEX COMPLAINT REFERRAL

ER MORTALITY: 0

DATE RM PATIENT’S AGE/SEX CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FINAL DIAGNOSIS SERVICES
ADMITTED NAME COMPLAINT FOR
REFERRAL
 ICU MORTALITY: 0

DATE RM PATIENT’S AGE/SEX CHIEF ADMITTING DIAGNOSIS PHYSICIAN REASON FINAL DIAGNOSIS SERVICES
ADMITTED NAME COMPLAINT FOR
REFERRAL