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    Referral-Nene Leon Placero

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    NABILOG COMMUNITY PRIMARY HOSPITAL

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    Referral-Nene Leon Placero

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    NABILOG COMMUNITY PRIMARY HOSPITAL
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    REFERRAL-NENE LEON PLACERO

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    Referral-Nene Leon Placero

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    NABILOG COMMUNITY PRIMARY HOSPITAL

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    CENTRAL VISAYAS HEALTH REFERRAL SYSTEM

    Clinical Referral Form

    Patient Code: 240625-060-102713604512

    Name of Referring Facility: Nabilog Community Primary Hospital


    Facility Contact #: 09051838021/9954641253
    Address: Negros Oriental, Tayasan, Tambulan
    Referred to: Negros Oriental Provincial Hospital Department: ER IM
    Address: Negros Oriental, Dumaguete City (Capital), Negros Oriental
    Date/Time Referred (ReCo): June 25, 2024 10:27 AM Date/Time Transferred:
    Name of Patient: NENE LEON PLACERO Age: 70 years Sex: Male Status: Married
    Address: Region VII, Negros Oriental, Tayasan, Bago
    PhilHealth Status: PhilHealth # :
    Covid Number:
    Clinical Status:
    Surveillance Category:
    Discharge Clinical Status:
    Discharge Surveillance Category:
    Case Summary (pertinent Hx/PE, including meds, labs, course etc.):
    CC: Body weakness

    HPI: 2 days PTA, patient was found lying on the floor, awake, unable to move both lower extremities, with
    incomprehensible speech. No meds given, no consult done. ODA, symptoms persisted hence decided to seek ER
    consult.

    ROS: (+) productive cough x 1 week

    PMH:
    Known hypertensive but was noncompliant to meds

    PE:
    Awake, incomprehensible speech, NIRD, GCS 12 (E4V2M6)
    VS:
    T 36.4
    PR 75
    RR 32 cpm
    BP 180/90 to 200/110
    SaO2 99% at room air

    Ht 161 cm
    Wt ~50 kg

    HEENT: Anicteric sclerae, pink conjunctivae, PERRLA


    CVS Adynamic precordium, NRRR
    C/L (+) Coarse crackles, bilateral
    EXT: CRT <2s
    Neuro: GCS 12 (E4V2M6)
    Motor RUE 0/5 LUE 3/5 RLE 2/5 LLE 2/5

    Family apprised of patient's condition and advised referral to a tertiary institution for CT scan and further evaluation and
    management but refused.
    Heplock inserted
    Meds given:
    1. Amlodipine 10 m/tab 1 tab OD
    2. Losartan 100 mg/tab 1 tab OD
    3. Nicardipine 2 mg IV x 1 dose then Nicardipine drip was started (AD 3 mg/h) and titrated to maintain MAP of 110-130.
    Stock consumed.
    4..Clonidine 75 mcg/tab 1 tab SL q 6H prn for SBP >160
    5. Citicholine 500 mg BID
    5. Cefuroxime 500 mg/cap 1 cap BID then shifted to Cefuroxime 750 mg IV q 8H
    6. Azithromycin 500 mg/tab 1 tab OD

    On hospital D1 (6/25/24), patient had onset of fever (T 38.6 C) and desaturation to as low as 85% at RA. PCM 500
    mg/tab was given and O2 support was started. BP ranged from 160/100 to 190/100. GCS 12 (E4V2M6). Family then
    agreed to be referred.

    Latest vital signs (10 AM):


    T 36.9
    RR 21
    PR 103
    BP 140/80 mmHg
    SaO2 95% at 8 lpm via face mask
    GCS 12 (E4V2M6)

    Latest RBS (9 10 am) 193 mg/dl

    No other labs currently available in our institution

    A: ACVD, bleed vs infarct; CAP-HR

    Summary of ReCo (pls. refer to ReCo Guide in Referring Patients Checklist):


    Ongoing medications:
    1. Cefuroxime 750 mg IV q 8H (Going D1, Last given 9 am 6/25/24)
    2. Azithromycin 500 mg/tab 1 tab OD (Going D2, Last given 6 pm 6/24/24)
    3. Amlodipine 10 m/tab 1 tab OD (Last given 12 pm 6/24/24)
    5. Losartan 100 mg/tab 1 tab OD (Last given 6 pm 6/24/24)
    6..Clonidine 75 mcg/tab 1 tab SL q 6H prn for SBP >160 (Last given 6 am 6/25/24)
    7. Citicoline 500 mg IV BID (Last given 9 am 6/25/24)
    8. PCM 500 mg/tab 1 tab q 4H prn for fever (Last given 6 am 6/25/2024)

    Attachments:
    Heplock
    FBC
    NGT

    ICD-10:
    J13.3 - Pneumonia [bronchopneumonia]due to Streptococcus
    pneumoniae, high risk
    I64 - Stroke, not specified as hemorrhage or infarction; Cerebrovascular Accident (CVA)
    Cardioembolic CVA

    Reason for referral:


    Further Evaluation and Management

    Name of referring MD/HCW: Dr. PATRICIA CAMILLE A NAVARRO


    Contact # of referring MD/HCW: 09051838021
    Name of referred MD/HCW- Mobile Contact # (ReCo):

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