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ILOCOS TRAINING AND REGIONALMEDICALCENTER

City of San Fernando, La Union


March 1-2, 2018

MEDICAL WARD 2
Admission Information Problem List Medications Notes and Laboratories
MACARAEG, Angelo, De Admitting Diagnosis: Medications: IVF: PLRS 1L x 12 hours
Guzman T/C PAOD, R/O DM Foot; 1. Paracetamol 500mg/tab, Diet: DM Diet
63/M/M Hypertension Stage II, S/P PRN for fever and pain
San Fernando, La Union CVD (2106) 2. Clindamycin 300mg/cap 2 CBC 2/24 2/26
7-10-1954 caps TID Hgb 137 121
2015-0025174 PWI: 3. Irbesartan 150mg/tab OD Hct 42 37
PAOD, Left Foot; Cellulitis, 4. Tramadol 50mg/cap TID WBC 14.08 6.83
DOA: 02-23-2018 Left Foot; Hypertension 5. Cloxacillin 500mg/cap q6 N 82.8 73.8
HD: 5th Stage II 6. Cilostazol 50mg/tab BID
L 6.0 12.6
7. Oxacillin 1gm/vial q6
Mono 10.2 6.6
RIC: Dr. FIANZA IM-CARDIO:
CCIC: JI Depalobos Infected Wound, Left Leg Eo 0.9 6.4
secondary to Puncture, Baso 1.0 0.6
Non-diabetic Plt 325 291
BLOOD type O+

Na K BUN Crea HbA1C


2/24 139 3.5 6.63 120.85 5.8%
2/26 98.58

PT INR CT BT
2/24 16.1 1.29 2 mins 30 2 mins
secs

FBS TC Trig HDL LDL


2/24 6.89 2.69 0.47 1.03 1.4

URINALYSIS 2/27
Color Yellow
Trans Slightly Turbid
WBC 0-2
RBC 0-2
GLU Negative
CHON Negative
pH 6.0
Sp.gr 1.030

Wound Gram Stain


Gram Positive Cocci +2
in pairs short chains
WBC +1
Epithelial Cells +2
Gram Negative Bacilli +2

ANGALA, Aurelia, Literal Admitting Diagnosis: Medications: IVF: PLRS 1L x 12hours


44/F/M Bowel Ileus; S/P 1. Cefixime 400mg/tab OD Diet: Soft Diet
Santa Cruz, Ilocos Sur Cerebrovascular Disease, 2. Levofloxacin 500mg/tab
3-13-1973 Infarct; Systemic Lupus OD CBC 2/21 2/23 2/25 3/1
2017-0035435 Erythematosus 3. Phenytoin 100mg/tab TID Hgb 122 105 115 108
4. Amlodipine 10mg/tab OD Hct 39.9 33 36.3 34.7
DOA: 02-21-2018 PWI: 5. Irbesartan 150mg/tab OD WBC 20.84 20.04 26.96 15.41
HD: 7th Hospital Acquired 6. KCl tab TID N 84.2 83.4 87 70.3
Pneumonia; Seizure 7. ISMN 25mg/tab OD
L 10.1 11.9 9.3 16.9
RIC: Dr. FIANZA Disorder secondary; 8. ASA 80mg/tab OD
Mono 5.0 3.5 3.2 7.3
CCIC: JI Depalobos Neuropsychiatric Lupus; 9. Clopidogrel 75mg/tab OD
S/P CVD Infarct, RPCA 10. Omeprazole 40mg/cap OD Eo 0.5 0.9 0.2 5.4
30 mins prebreakfast Baso 0.2 0.3 0.3 0.1
11. Hydroxyzine 2.5mg/tab Plt 251 179 170 158
ODHS BLOOD type B+
12. Hydrochloroquin Pro Time 14.1
200mg/tab OD INR 1.12
13. Furosemide 20mg/tab OD
14. Prednisone 10mg/tab, 3 Pleural Fluid Culture No Growth after 3 days
tabs in AM, 2 tabs in PM (2/19/2018) of Incubation
15. Ceftazidime 1gm IV q8 Pleural Fluid AFB Negative
Pleural Fluid Gram No microorganism seen
Stain
Na K BUN Crea
2/21 139 3.3 4.41 50.67
2/23 3.5
3/1 139.9 3.21

Troponin I (2/22/2018) Negative

ABGs 2/22 2/24 2/26


pH 7.359 7.509 7.532
pCO2 57.8 35.5 35.1
pO2 64.3 65.7 49.6
BEecf 6.41 4.56 6.19
HCO3 31.9 27.6 28.9
tCO2 33.6 28.7 29.9
sO2 91.5 94.9 90.0

Cardiac Ultrasound
No fluid collection within pericardial
sac
Minimal free fluid collection on left
hemithorax

Repeat Cranial CT SCAN (02-27-18)


Regressing infarcts both occipital and
parietal lobes

Repeat Chest X-Ray (03-01-18)


Regression of Bilateral Pneumonia
Minimal Pleural Effusion, Left

OLIVA, Ruben, Agas Admitting Diagnosis: Medications: IVF: D5NSS 1L x 12 hours


41/M/M Community Acquired 1. Ceftriaxone 2gm + 90cc Diet: DAT with SAP
Santol, La Union Pneumonia – Moderate PNSS to run for 1 hour q24
10-10-1976 Risk; T/C Bell’s Palsy R/O 2. Omeprazole 40mg/cap OD CBC 2/23 2/24 2/26 2/28
2018-0005706 CVD Infarct 30 mins prebreakfast Hgb 86 83 80 73
3. Vitamin B Complex tab OD
DOA: 02-23-2018 PWI: 4. Celecoxib 200mg/cap BID Hct 22.6 21.7 20.6 19.4
HD: 5th Bell’s Palsy vs CVD; AKI on 5. Acyclovir 400mg/tab q6 WBC 30.72 29.91 30.50 32.28
top of CKD; Anemia 6. Lactulose 30cc now N 66.1 71 60.1 25.2
RIC: Dr. secondary to sepsis L 17.9 17.1 21.1 14.3
MANGABAT/SHRESTHA Mono 13.7 9.6 16.4 58.7
CCIC: JI Depalobos ORL-HNS:
Eo 0.6 0.4 0.7 1.6
Facial Paralysis, Right T/C
Baso 1.7 1.9 1.7 0.2
Bell’s Palsy probably
secondary to Metabolic Plt 138 108 122 102
Disorder BLOOD type B+
Reticulocyte 0.4%
Count

URINALYSIS 2/23 2/28


Color Straw Light Yellow
Trans Clear Clear
WBC 0 0-1
RBC 0-1 0-2
GLU Negative Negative
CHON Negative Negative
pH 6.0 6.5
Sp.gr 1.030 1.030

Na K iCa BUN Crea


2/23 129 4.02 1.91 22.98 317
2/28 264.23

Occult Blood (2-28-18)


Positive

Urine Gram Stain (2-28-18)


Negative

LIBAO, Bernardo, Admitting Diagnosis: Medications: IVF: D5NM 1L x KVO


Mabalot Chronic Obstructive 1. Piperacillin Tazobactam Diet: LSLF
71/M/S Pulmonary Disease in Acute 4.5g IV q6
Rosario, La Union Exacerbation in Cor 2. Azithromycin 500mg/tab CBC 2/26 2/27 3/1
02-21-1947 Pulmonale OD Hgb 100 100 106
2015-0013479 3. Carvedilol 6.25mg/tab, ½ Hct 29.8 30.4 31.6
PWI: tab BID WBC 29.82 21.46 13.30
DOA: 02-25-2018 HCVD in CHF FC IIIC 4. Furosemide 20mg/tab OD N 93.5 91.4 83.4
HD: 3rd COPD not in AE 5. Spironolactone 25mg/tab
L 3.9 5.8 13.7
Liver Cirrhosis secondary to OD
Mono 2.2 2.4 1.7
RIC: Dr. MANGABAT CALD 6. Budesonide + Formeterol
CCIC: JI Depalobos 320/90 2 puffs BID Eo 0.3 0.2 0.9
7. Hydrocortisone 100mg IV Baso 0.1 0.2 0.3
q6 Plt 356 301 286
8. Lactulose 300ml ODHS BLOOD type
9. Doxofylline 400mg/tab, ½ Pro Time 14.3
tab BID INR 1.14
10. Montelukast 10mg/tab
ODHS Na K BUN Crea
11. Salbutamol + Ipratropium 2/26 138 3.2 6.54 85.98
neb q8 2/26 3.8
3/1 142 3.8 98.18

URINALYSIS 2/26
Color Light Yellow
Trans Turbid
WBC TNTC
RBC 3-6
GLU Negative
CHON Negative
pH 6.0
Sp.gr 1.020

DULAY Jr., Angelo, Admitting Diagnosis: Medications: IVF: D5NM 1L x KVO


Frigillana To consider Deep Vein 1. Rosuvastatin 20mg/tab Diet: DAT with SAP
70/M/M Thrombosis ODHS
Sison, Pangasinan 2. Tramadol 50mg/tab TID CBC 2/27 3/1
5-23-1947 PWI: 3. Oxacillin 1gm IV q6 Hgb 135 111
2017- 0006414 To consider Deep Vein 4. Ciprofloxacin 500mg/tab
Thrombosis q12 Hct 39.5 32.2
DOA: 02-26-2018 5. Cilostazol 100mg/tab q12 WBC 12.10 9.43
HD: 3rd before meals N 67.6 65.8
L 23.4 22.4
RIC: Dr. FIANZA/SUMEE Mono 6.7 8.0
CCIC: JI Depalobos
Eo 1.7 3.3
Baso 0.6 0.5
Plt 207 186
BLOOD type
Pro Time 15.8
INR 1.27

Na K AST ALT
2/268 139.8 4.38 34 24.4

FBS TC Trig HDL LDL


2/28 5.04 3.13 0.72 1.69 1.1

Sputum Gram Stain


Epithelial cells +4
Gram Negative Bacillus +2
Gram Positive Bacillus +2
Gram Negative Cocci +3
Gram Positive Cocci +2 in singles,
pairs, chains
Sputum KOH
No fungal elements seen

BERMUDEZ, Ismael, Admitting Diagnosis: Medications: IVF: PLRS 1L x 12hours


Aballog Upper Gastrointestinal 1. Tranexamic Acid 500mg IV Diet: NPO
42/M/M Bleeding secondary to q6
Tagudin, Ilocos Sur portal hypertension – 2. Co-Amoxiclav 1gm/tab CBC 2/27 3/1
12-29-1975 bleeding esophageal varices BID Hgb 101 94 96
2018-0006526 3. AlMgOH 30ml TID Hct 31.9 30 30.2
PWI: 4. Sucralfate 1gm/tab q6 WBC 12.91 8.92 6.48
RIC: Dr. MANGABAT Upper Gastrointestinal 5. Azithromycin 500mg/tab N 76.8 54.5 62.9
CCIC: JI Depalobos Bleeding secondary to OD
portal hypertension – 6. NAC 600mg/tab in ½ glass L 14.8 28.6 27.2
bleeding esophageal varices of water ODHS Mono 2.0 8.4 2.7
7. Omeprazole 40mg/vial OD Eo 6.0 8.1 6.8
Baso 0.4 0.4 0.4
Plt 324 300 164
BLOOD type O+
Pro Time 14.8
INR 1.18

Na K BUN Crea AST ALT


2/27 140.5 4.63 19.94 400.81 16.4 22.5

Tot. Protein Albumin Globulin AG Ratio


2/27 61.0 37.9 23.1 1.6:1.0

Occult Blood (2-28-18)


Positive

Ultrasound of the Whole Abdomen (3-1-18)


Cholesteroloses
Sonographically unremarkable liver, pancreas,
spleen, kidneys, urinary bladder, and prostate
gland

TOBIAS, Leonardo, Admitting Diagnosis: Medications: IVF: PLRS 1L x 12 hours


Benavese Aspiration Pneumonia 1. Ampicillin-Sulbactam 1.5g Diet: Soft Diet with SAP
87/M/M cannot totally rule out IV q6
Naguilian, La Union Pulmonary Embolism; 2. Clindamycin 300mg/cap 2 CBC 2/26
11-29-1930 Tonsillar Mass probably caps TID Hgb 109
2007-0025189 Malignant 3. NAC 600mg/tab in ½ glass Hct 33.9
of water ODHS WBC 6.35
DOA: 02-26-2018 PWI: 4. Salbutamol + Ipratropium N 68.9
HD: 4th Aspiration Pneumonia neb q8
L 24.6
cannot totally rule out 5. Hydrocortisone 100mg IV
Mono 5.3
RIC: Dr. FIANZA Pulmonary Embolism; q12
CCIC: JI Depalobos Tonsillar Mass probably 6. Doxophylline 400mg, ½ Eo 0.9
Malignant tab BID Baso 0.3
7. Budesonide+Formoterol 2 Plt 298
ORL-HNS: puffs BID BLOOD type O+
Oropharyngeal Tosillar Pro Time 13.7
Mass, Left, T/C Malignancy INR 1.09

BUN Crea AST ALT


2/26 3.34 73.93 24.8 12.0

Repeat Chest X-Ray (03-01-2018)


Initial: Pulmonary Hyperaeration
Bilateral Pneumonia
Atherosclerotic Aorta
Thoracic Spondylosis