CENTRAL VISAYAS HEALTH REFERRAL SYSTEM

Clinical Referral Form

Name of Referring Facility: Talisay District Hospital

Facility Contact #: (032) 273 3226 / (032) 273 3713
Address: San Isidro, City Of Talisay, Cebu
Referred to: Vicente Sotto Memorial Medical Center Department: ED Complex
Address: Sambag II (Pob.), Cebu City (Capital), Cebu
Date/Time Referred (ReCo): December 21, 2018 05:32 PM Date/Time Transferred:
Name of Patient: TOMASA MABIA PESTAÑAS Age: 82 Sex: Female Status: Married
Address: Cansojong, City Of Talisay, Cebu
PhilHealth Status: None PhilHealth # :
Case Summary (pertinent Hx/PE, including meds, labs, course etc.):
1 MONTH PTA ONSET OF ON AND OFF NON-PAINFUL HEMATOMAS WAS NOTED WHICH SPONTANEOUSLY
RESOLVES.
1 WEEK PTA ONSET OF BODY MALAISE/BONE PAINS. AROUND THIS TIME, ONSET OF PRODUCTIVE COUGH
WITH YELLOW SPUTUM WAS ALSO NOTED (-) FEVER. DAY PTA PERSISTENCE OF SYMPTOMS WERE NOTED,
SOUGHT CONSULT AND WAS ADVISED ADMISSION.

(+) HPN
(-) DM
(-) BA
(-) PREV ADMISSIONS/SURGICAL OPERATIONS

PHYSICAL EXAMINATION
GEN SURVERY: AWAKE, ALERT
SKIN: (+) MULTIPLE HEMATOMAS, SENILE TURGOR, WARM
C/L: ECE, CBS
CVS: AP, DHS
EXT: NO EDEMA, NO DEFORMITIES
MOTOR: 5/5 ON ALL

MEDS:
1. CEFUROXIME 750MG IV DRIP Q 8H (DAY 7)
2. NAC 600 MG /TAB, 1 TAB BID
3. AMLODIPINE 10MG, 1 TAB PO OD
4. LOSARTAN 50MG/TAB, 1 TAB PO BID
5. CELECOXIB 200MG/TAB, 1 TAB PO OD

LABS DONE:
CBC, PBS, UTZ WA, CXR PA, XRAY OF LUMBOSACRAL AREA, NA, K, CREA, BUA, FBS, LP, HBA1C- LAB
RESULTS ATTACHED

VITAL SIGNS
BP: 100/70
HR: 80
RR: 20
TEMP 36.5

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

TRANSFER VIA AMBULANCE WITH AN ACCOMPANYING NURSE

Diagnosis/Impression:
R/O BLOOD DYSCRASIA, CAP-MR, HCVD, IMPAIRED FASTING GLUCOSE, OSTEOARTHRITIS OF LUMBAR
SPINE, OSTEOPOROSIS

Reason for referral:

FOR HEMATOLOGIST CONSULT/ CO-MANAGEMENT

Name of referring MD/HCW: Dr. MARIGOLD BAGABOYBOY ALBURO

Contact # of referring MD/HCW: 0942 494 6804
Name of referred MD/HCW- Mobile Contact # (ReCo):