Good evening ma'am. We have a referral from IM-ER.

Guese, Donne 34/M/CPL/PA

Patient is a known case of ischemic dilated cardiomyopathy initially presenting as

dyspnea and easy fatiguability.

7 days PTR, patient noted intermittent, colicky pain, 7/10 over the right upper
quadrant, no bowel movement. No consult was done. No medication was taken. There
was no bowel movement during the interval history, daily bouts of the abdominal
pain..

2 hours PTC , patient noted dyspnea and easy fatiguability which prompted consult
to IM ER

Patient currently on Aspirin, carvedilol, spironolactone, enalapril Rosuvastatin

and insulin glargine

Awake alert, in respiratory distress

150/100, HR 126, RR 24, 36.8
Anicteric sclearae, pink palpebral conjunctivae
Symmetrical chest expansion, clear breath sound
Protruberant abdomen, NABS, (+) direct tenderness over the right upper quadrant,
soft,
Grossly normal extremities
Dre: no fissure, no skin tags, good sphincteric vault, no tenderness

CBC Hgb 180, Hct 0.53, WBC 7.8, Seg 0.47, Lym 0.46, Plt 156.

Abdominal x-ray - fecal stasis

A> t/c fecal stasis

P> no immediate surgical intervention warranted at this time

Continue present medical management
For CBC, abdominal flat plate
Suggest fleet enema of..

Thank you po mam

Good evening, ma'am. We have a referral from Neurosurgery: TAPEL, TREASURE 3/ F/

ODD referred for thoracoabdominal clearance.

Patient came in 6 hours post injury, airway patent, no active bleeding

NOI: Fall
TOI 1800H
POI Bacoor Cavite
DOI: 24 July 2019

Patient was playing when she was pushed and fell down to the pavement. No loss of
consciousness, no seizure, with dizziness and 2 episodes of vomiting previously
ingested food. Persistence of symptoms prompted consult.

Asleep, arousable, alert, not in distress

HR 90 RR 33 T 36.9°C
No swelling, no tenderness, no racoons eye, no battle sign, (+) soft tissue
swelling over the occipital area
Anicteric sclerae, pink palpebral conjunctiva
No external signs of injury on the chest, abdomen
Symmetrical chest expansion, clear breath sounds
Flabby abdomen, normoactive bowel sounds&, soft, non tender
Grossly normal extremities

Plain cranial CT scan: no intra/axial hematoma or lesions noted, no

ventriculomegaly, no infarcts or hemorrhage, no fracture (read by CPT Trinidad)

Chest and TCage - No pulmonary contusion or pneumothorax, no fracture

A > Soft Tissue Contusion, Occipital Area; Mild Head Injury secondary to fall (24
July 2019)

Plan:
No immediate intervention warranted from GS Standpoint
Continue present neurosurgical management
Diagnostics:
- Canial CT scan
- CXR and Tcage
Suggest referral to pedia for co management
Cold compress for 15 min QID on the affected site
Head precautions advised

Thank you, ma'am.

Good afternoon sir. We have a new referral from OBW. Ordiz, Hazel 41/F/EDW/PA

Patient is a known case of G2P1 (1001) Pregnancy Uterine, 10 6/7 weeks AOG in
Threatened Miscarriage; Previous LTCS 1 for arrest in cervical dilation initially
mainifesting as hypogastric pain. Patient is currently on her 1st hospital day.

4 hours PTR, patient noted right lower quadrant pain, colicky, 5/10. There was no
vomitting, no anorexia, no febrile episodes.

Awake, alert, not in distress

100/70, HR 90, T 36.4, RR 19, 98% I 1800, O 750
Anicteric sclerae, pink palpebral conjunctivae,
Symmetrical chest expansion, clear breath sound
Flabby abdomen, NABS, soft abdomen, noted direct and rebound tenderness, no
rovsings sign, (+) psoas sign, no obturator sign

CBC (23 July 19): Hgb 120, Hct 0.34, WBC 9.6, Seg 0.69, Lym 0.26, Plt 335

UA (23 July 19): light yellow, slightly turbid, spgr 1.020, sugar negative, protein
negative, RBC 0-2, pus cell 0-3

Plan:
For repeat CBC
Suggest RLQ UTZ
Continue PNSS ILx8H
Serial abdominal examination q2H

Thank you po sir.

Good morning ma'am. Update on patient MORALES, ERLINDA 73/F/PA

Hospital Acquired Pneumonia, Resolving; Duodenal Adnocarcinoma, stage III; Type 2

Diabetes Mellitus; Hypertension stage II; S/P Percutaneous Transhepatic Drainage
( 28 June 2019).
Currently patient is comfortable, non tachycardic, non tchypneic, had no abdominal
pain and tolerates soft diet

BP 120/80 CR 90 RR 20 T 36 O2 sat 98%

Icteric sclera, pink palpebral conjuctivae
Symmetric chest expansion clear breath sounds
Adynamic precordium
Flabby abdomen, normoactive bowel sounds, soft, nontender, intact PTBD drain, with
bilous output

TI: 1670cc
To: 2520cc
UO 105cc/kg/hr
PTBD 460cc

Progressive Diet
Continue TPN 1500 kcal in 6 divided doses
Meds:
Tranexamic acid 500mg TIV q8hours
Fluconazole 200mg TIV q12 (D9)
Ertapenem 1g TIV 24( D15)
Paracetamol 600mg TIB q4 prn for fever
NAC 600mg tab 1 tab in 50cc water ODHS
Irbesartan 300mg tab 1 tab OD AM
Combivent neb q12 hours
KCL 1 tab TID
NaCl 1 tab TID
Follow up Pulmo referral for final disposition
Refer to IDS regarding ET tip GS/CS results
Encourage ambulation and deep breathing exercises
Daily wound care
Monitor vital signs q2
Monitor I&O q shift and record
Weight patient every 3 days and record

CBC
hgb 115
Hct 0.34
Wbc 6.60
Seg 0.65
Lym 0.18
PLT 259

COAG
PT 11.7
INR 0.97
%Act 91.6
PTT 26.4

Thank you ma'am

Good morning ma'am. Update on patient

MALAPAYA, WILFREDO
70/M/EDF/PAF

Dx: Complete Intestinal Obstruction secondary to Sigmoid Tumor, Resolved; Hospital

Aquired Pneumonia; Hypertension Stage II; Parkinson's Disease; Benign Prostate
Enlargement
Patient is able to tolerate current diet of milk with no abdominal pains. No
associated symptoms such as difficulty of breathing, headache, nausea or vomiting.
No fever.

O > awake, conversant, not in distress

120/90mHg, 36.0C, 89bpm, 20cpm, 97% O2 sat, 58kg
Anicteric sclerae pink palpebral conjunctivae
Symmetric chest expansion clear breath sounds
Adynamic precordium normal rate regular rhythm
Flatnbdomen, normoactive bowel sounds, soft, nontender pinkish stoma, well-
coaptated wound
Full and equal pulses, no deformities on extremities

Ti: 4795
To: 3400
UO: 2.44cc/kg/hr
Colostomy bag: 180
JP Left: 44cc, serous
JP Right: 38cc, serous

Serum Electrolytes (24 July)

Na 128.8
K 3.42
Cl 97
iCa 1.04
iMg 0.43

P > Patient in SIL

Progressive diet
Start KCl correction suggested by IM:
- IVF: PNSS 1L + 40meqs KCl x 80cc/hr
- Continue KCl tab to complete 3 days
- Repeat serum Electrolytes after
Continue current medications
Follow up histopath results
Follow up Chest CT scan and ERCP
Monitor VS Q2H and record
Monitor Input and output every shift and record
Refer accordingly

Thank you ma'am.