PATIENTS ADMISSION RECORD
Patient name: LUCERO, JAIME S.
337
Age: 65 Sex: male Room no.
Attending doctor: MONIS, MANUEL C., MD
Hosp No: 172301
Adm No: 646790
Admitting doctor: DIWAS, ANALIZA W. MD
09/29/2016
Adm Date/Time:
HISTORY &PE
Admitting diagnosis:
CAP-MR t/c COPD in acute exacerbation
Chief complaint:
Cough, fever
Reason for admission:
Cough, ever
Brief history of present illness/ OB history:
4 days PTA, patient started to experience productive cough with yellowish
expectorate associated with undocumented febrile episodes and difficulty of
breathing. Patient took ion paracetamol which provided temporary relief. Patient
took in maintenance medications. No consult done. Persistence of symptoms and
progression of dyspnea prompted consult in an outside institution. Venoclysis was
started. Patient opted to transfer to LMC, hence admission.
Past medical history
(+) HPN
(+)COPD
(-) Cataract, right eye
(-) allergies]
(-) previous operations
Personal and social history:
(+) smoker, 40 pack years, stopped 1 year ago
Non- alcoholic beverage drinker
Physical examination (pertinent findings per systems)
General survey:
Conscious, coherent, in respiratory distress
Vital signs:
BP: 120/70
HR: 119
RR: 32
T: 36
Skin:
Warm, moist, no pallor, no jaundice
Head &neck:
(+) cloudiness of cornea, right eye, anicteric sclerae, pink palpebral
conjunctivae, no TPC, no TPC, no CLAD, no nasal discharge
Thorax:
Symmetrical chest expansion, no retractions, adynamic precordium,
tachycardic, regular rhythm, (+) diffuse rales and wheezes.
Abdomen:
Flabby, normoactive bowel sounds, soft, non-tender
Extremities:
No gross deformities, full and equal pulses, no edema
Lymph nodes:
No cervical lymphadenopathies
Genitalia:
N/A
Rectal:
N/A
Neuro examination:
Conscious, coherent
ADMISSION AND DISCHARGE RECORD
Admission no.:
646790
Hospital
no. :.172301
Account no.:C200
Room/rate: 337/ P 1,800.00
Last name:
LUCERO
First name:
JAIME
Middle name:
SABADO
Age
65
Address: DMMMSU COMP. BRGY SAN MARTIN, Bacnotan,
La Union
Birth place: BANGAR, LA
Birth date
Tel#
UNION
10/20/195 09203988454
0
Sex
M
Civil
status
Married
How the patient was
admitted
(+) Ambulatory
()
Wheel chair
( )stretcher
()
carried by rel
Barangay captain
Nationality: FILIPINO
Religion: BAPTIST
Father:DECEASED
Mother: DECEASED
Spouse: ERLINDA GAPASIN
Whm to notify in case of
emergency
MRS. ERLINDA GAPASINLUCERO
Responsible for hospital
account
PATIENT
Occupation:
TEACHING
Address: N/A
Address:
Address:
Relationship: WIFE
Address: SAME AS PATIENT
Tel#
Tel#
Tel#
Tel#
09305278858
Employer:
Address:
Tel#
09305278858
SSS/GSIS No.:
Remarks PHIC/SC
Hospitalization Plan
Employer
Employer: DMMMSU-NLUC
Address: BACNOTAN, LA UNION
Account Name:
IMS WELLTH CARE INC.
Admission date& time: Sep 29,2016
9:10 PM
Service:
MEDICINE
Admitting Clerk:
CORTEZ, YEN MAE BATAY-AN
Informant: MR. JEFFERSON PILAR
Ralation to patient: SON IN LAW
Address: SAME AS PATIENT
Tel#: 09305278858
CHEST XRAY
Patient Name
LUCERO,JAIME
SABADO
Patient ID
172301
Room No
337
Exam: CR CHEST PA
Sex
M
Birthdate-Age
10/20/1950-65
Exam No.: 1175216092937763
ref. physician:348, MONIS MANUEL C.
10:56PM
Exam date :09/29/2016
ACCOUNT: IMS WELLTH CARE INC.
Reg. Adm.#: 646790
accession#: 337930X
11:40:39PM
Result date :9/29/2016
REPORT
CXR:
Parahillar/ paracardiac infiltrates are noted.
The right paracardiac infiltrates are the most abundant.
Bronchovascular markings are prominent.
Heart is enlarge with LVE. Aorta is sclerotic.
Diaphragm is normal in level.
Included bones are intact.
IMPRESSION:
Bilateral pneumonia
Bronchovascular prominence, consider bronchitis or age related change.
Cardiomegaly, LVE, with atherosclerotic aorta.
Thanks for referring,
GAERLAN, JEROME A. MD.FPCR,FUSP,FCTMRSISP
radiologic sp. RADILOGY Radiologist
Patient Name
LUCERO,JAIME
SABADO
Patient ID
172301
Room No
337
Sex
M
Birthdate-Age
10/20/1950-65
Exam: CR CHEST PORTABLE
Exam No.: 1175216100339294
ref. physician:348, MONIS MANUEL C.
Exam date :10/03/2016 5:15AM
accession#: 337124X
Reg. Adm.#: 646790
Result date :10/04/2016 5:15:05AM
REPORT
CHEST AP
With the due consideration to differences in technical factors, current study since 92-2016 hows persistence of bilateral lung infiltrates with slight regression in the left.
The right paracardiac infiltrates are still abundant.
Bronchovascular markings remain prominent.
Heart is enlarged with LVE. Aorta is sclerotic.
Right hemidiaphragm is tented.
Included bones are intact.
IMPRESSION:
Bilateral pneumonia with slight regression in the left. Right-sided pneumonia still
evident.
Bronchovascular prominence; consider bronchitis or age-related change.
Cardiomegaly, LVE, with atherosclerotic aorta.
Plurodiaphragmatic adhesions, right.
Thanks for referring,
TADAOAN,CAROL GRACE D FPCR,FUSP, FCTMRISP
radiologic sp. RADILOGY Radiologist
MEDICATION
1.
2.
3.
4.
5.
HYDROCORTISONE(HYDROVEX)100MG/VIA,200MG EVERY 4 HOURS
SULACILLIN 1.5GRAMS IV EVERY 6 HOURS
AZITHROMYCIN 500MG 1 TAB DAILY
NAC(FLUIMUCIL)600MG 1 TAB IN 50CC OF WATER 2X A DAY
5. DOXOFYLLINE 400MG TAB 2X A DAY
ELECTROCARDIOGRAPHIC REPORT
