You are on page 1of 9

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