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TRAUMA MALE A
PATIENT DIAGNOSIS MEDICATIONS DIAGNOSTICS
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1Lx16hour E
TM-A INITIAL DX: DIET: DAT with SAP 1/102020
ANCILLARY:
MULTIPLE PHYSICAL
INJURY SECONDARY MEDICATION:
LEDESMA, EDGAR SERANO TO VEHICULAR 1. Losartan 50 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; MULTIPLE mg BID 1/06/20 15.3 151 0.43 75.2 16.9 7.2 0.4 0.3 267 102 36 350
53/M
RIB FRACTURE 3RD-5TH 2. Amplodipine
RIGHT CLAVICULAR 10 mg OD
FRACTURE RIGHT, 3. Ampi-sul 1.5
DOB:06/15/66 PULMONARY gm TIV q8
CONTUSION RIGHT 4. Salbutamol +
CHEMISTRY CREA BUN Alb Globu NA K CL FAS GLU CHOOL TRIGL HDL LDL ALT AST TB TP A/ CEA B1/B2
DOA: 01/06/20 Ipratropium lin E Y G
neb q6 1/11/20 28 27.80 60 94 221. 55 1.0 86.8/
3 36.2
5. Nicardipine
drip: 90cc 1/09/20 6.10 3.43 0.77 0.94 2.14
CC: VEHICULAR ACCIDENT pNSS + 1amp 1/06/20 142. 4.06
Nicardipine to 1
Novi
NITRAT Leukocy
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x E te
TM-A INITIAL DX: 20gtts/min 1/18
DARK
TURBID 1.025 6.5 ++ - +++ - - +++ - - >100 0-3 RARE - ++
RED
DIET: Soft diet
MEDRAZO, CHRIS KYLE OLIVAS PENTRATING INJURY
RIGHT LOWER ANCILLARY:
7/M QUADRANT AREA
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
MEDICATION:
DOB:10/11/2012 1/18 14.6 104 0.31 71 15 12 0.8 0.3 371
1. Ampicillin
DOA: 01/18/20 sulbactam
1g/IV q8
CC: PENETRATING INJURY 2. ketorolac
30mg/IV
3. tramadol CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
MONITOR VS q4 and
record
Monitor input and
output q shift
PLAN:
For
NITRAT Leukocy
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 8hr E te
TM-A INITIAL DX: DIET: Soft diet with SAP
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRAT Leukocyte RBC WBC EPITH HYALI BACTERIA
TM-A INITIAL DX: IVF: PNSS 1L x KVO E
DIET: DAT
Pneumohemothorax
left secondary to stab ANCILLARY: CTT output
CARDENAS, DARNLIE CASTRO wound T10 400cc
33/M S/P CTT Left
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
MEDICATION: 1/11/20 16.0 68 0.20 88.2 5.7 5.8 0.1 0.2 150 65 22 342
DOB:01/24/2020 1. Ampicillin- 1/14/2020 7.9 128 0.41 70.5 10.4 9.9 8.8 0.4 256 73 23 316
Sulbactam 1.5g IV
DOA: 01/11/2020 q8
2. omeprazole
CC: STAB WOUND 40mg/IV
CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
3. Ketorolac 30mg/IV
MONITOR VS q4 and 1/11/20 133 4.39
HISTORY: record 1/14/20 137 4.03
MGH
TOI: 11PM
DOI: 01/11/2020
BEV
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x KVO E
TM-A INITIAL DX: DIET: Diet for age
MULTIPLE PHYSICAL
ANCILLARY: CTT output
INJURY SECONDARY
CATAGGATAN, MIYA CALATA 400cc
TO VEHICULAR
ACCIDENT CEREBRAL MEDICATION:
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
33/M
CONCUSSION LINEAR 4. Ampicillin-
1/20/20 20.1 94 0.27 80 16 3.5 0 0.2 510
DOI: 01/16/2020
NITRAT Leukocy
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 8hr E te
TM-A INITIAL DX: DIET: Soft diet
Trauma Male B
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L X 8hr E
TM-B INITIAL DX: DIET: DAT with SAP 1/10/2020 LY Clear 1.015 7.5 - - ++ - - - - - 86 2 1 0 7
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L X 8hr E
TM-B INITIAL DX: DIET: DAT with SAP 1/16/2020
DARK
Clear 1.020 7.5 - Trace Trace - - + - - 33 258 2 0 31
YELLOW
INTRAPARENCHYMAL ANCILLARY:
BLEED PROBABLY MEDICATION:
ATTABAN, EDRIEL APOSTOL SECONDARY TO toclopramid 10mg/IV
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ARTERIOVENOUS Ceftriaxone 1g/IV
17/M 1/19/ 20 9.3 119 0.37 50 25 8.7 14.4 1.0 327 62 20 320
MALFORMATION Paracetamol 300mg/IV
DOB:Feb 28-2002 Mannitol 120cc/IV q4
output q shift
1/16 72 131 3.78
10th HOSPITAL DAY
PLAN:
Remove IFC
May transfer to Regular PT INR % Control PTT Control
ward
Continue all present 1/19//20 13
medication
Ketorolac 30 mg IV q8
DOA: 01/18/20 PRN for pain
Omeprazole 40 mg TIV
CC: FALL
q24
CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
NOI: FALL ISTRY SE MIN LIN G
Monitor VS q2 and
1/18 140 4.26
TOI: 10PM record /20
Monitor I & O qshift and
PT INR % Control PTT Control
POI: ILAGAN ISABELA record
PLAN:
1/18/2020 14.50 39.80
DOI: 1/18/20 Continue medical
management
2nd HOSPITAL DAY WOF neurodegeneration
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1Lx 8 hours E
TM-B INITIAL DX: DIET: NPO
1/18 6.2 115 0.34 81 7.6 9.1 1.6 0.3 190 79 27 335
MONITOR VS q4 and
record
Monitor input and
DOB:Oct 17 1972 output q shift
DOA: 09/22/2019 CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
PLAN:
MGH 1/19 141 3.93
CC: Refer to Family medicine
prior to discharge
ACCIDENT ketorolac 30mg/IVq8 1/20 26 158 0.47 89 4.5 6.6 0 0 390 90 30 338
DOA: 01/20/20
hook to 02 support at 2-
TOI: 9PM 3LPM via NC
DOI: 1/20/20
PT INR % Control PTT Control
1STHospital stay
1/20 14.30 32.20
DOA: 01/16/20 HEMATOMA RIGHT KCL drip: 90ccPNSS 1/19/20 9.5 94 0.27 87 6.6 5.1 0.1 0.3 222 90 32 352
INJURY SECONDARY
19/M TO VA, ACUTE MEDICATION:
SUBDURAL Ampicilin-Sulabctam
DOB: 1/20/2000
HEMATOMA RIGHT 1.5g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOA: 01/20/20 FRONTOTEMPOROPA Mannitol 150 cc IV q4 1/20 25 137 0.42 86 4.6 8.4 0 0.2 269
RIETAL WITH with BP precaution
CC: VEHICULAR ACCIDENT INTRACEREBRAL Ketorolac 30 mg/IV q8
HEMATOMA PRN for pain
NOI: VA BIFRONTAL AREA, Kcl drip: 900cc PNSS +
SUBARACHNOID 10 meqs Kcl x 1 hr x 2
TOI: 12AM HEMMORHAGE cycles CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
HEMATOMA, LEFT
68/M TEMPOROPARIETAL MEDICATION:
AREA Ampicilin-Sulabctam
DOB: 10/15/1951
1.5g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOA: 01/14/20 Mannitol 150 cc IV q4 1/14/20 25.1 128 0.38 88.2 3.7 8.7 0.1 0.2 230 90 31 338
1/18/20 10.8 131 0.38 68 14 5.8 10.7 0.7 351 89 31 346
with BP precaution
CC: LOC Ketorolac 30 mg/IV q8
PRN for pain
NOI: FALL Kcl drip: 900cc PNSS +
10 meqs Kcl x 1 hr x 2 CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
TOI: 7 PM cycles
1/14/20 136.40 3.71
DOI: 1/06/20
PLAN: 1/18/20 136 3.49
Continue medications
5th Hospital stay CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
1/14 136.40 3.71
/20
BURN
BURN INITIAL DX: IVF: PNSS 1L x 8h NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
TUMALIUAN, JHON CHRISTOPHER ELECTRICAL INJURY;
GACIAS NO CUTANEOUS MEDICATION:
BURN Cefoxitin 1g/IV q12
15/M
Metronidazole 500mg/
DOB: 06/14/2004 IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Omeprazole 40mg/IV
DOA: 01/18/20 OD
Ketorolac 30 mg/IV q8
CC: ELECTRICAL BURN Vit. K amp IV q8
NOI: ELECTRICAL BURN PLAN: CHEMISTRY CREA BUN AMY NA K CL MG CA CKMB TROP I AST ALT TB TP A/G CEA
AISLES RIGHT
AR INITIAL DX: IVF: PNSS 1L x 8h NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: Diet for age E
LIGUTAN, MA. MIKA ELLAH DIFFUSAL AXONAL
TALLADTAD INJURY SECONDARY MEDICATION:
TO FALL Cefoxitin 1g/IV q12
3/M
Metronidazole 500mg/
DOB: 03/26/2016 IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Omeprazole 40mg/IV 1/16 43.6 74 0.24 74 19 2.6 2.7 0.5 953 49 15 305
1/17 15.6 72 0.24 49.1 40.6 5.9 3.9 0.5 755 50 15 304
DOA: 01/16/20 OD 1/18 15.8 106 0.34 34 52 7 5 0.7 734 57 18 311
Ketorolac 30 mg/IV q8
CC: FALL Vit. K amp IV q8
DOI: 1/16/20
PT INR % Control PTT Control
POI: PENABLANCA
1/16 16 30.50
4TH HOSPITAL STAY
DOI: 1/18/20
POI: CLAVERIA, CAGAYAN
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 12hrs E
CCR INITIAL DX: DIET: 1/17 LY Clear 1.025 6 ++ - - - - - - - 0-2 0-2 0 0 ++
ANCILLARY:
ACUTE SUBDURAL
HEMATOMA MEDICATION:
JIMENEZ, JOSH-ZUA ESTRANO FRONTOTEMPOROPA
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
RIETAL RIGHT ACUTE
31/M 1/17 34 152 0.43 92 2.1 5.5 0 0.1 381
EPIDURAL MONITOR VS q2 and
DOB:12/8/88 HEMATOMA record
TEMPORAL RIGHT. Monitor input and
DOA: 1/17/2020 CONTUSSION output qshift CHEMISTRY CREA BUN AMY LIP NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
AS
HEMATOMA RIGHT 1/17 E 136 3.73
CC: VEHICULAR ACCIDENT FRONTAL PLAN:
SECONDARY TO Maintain MV setting
NOI: VA VEHICULAR Start oral hygiene:
ACCIDENT Chlorhexidine TID PT % INR CONTROL APTT CONTROL
DOI: 1/17/20 For stat ABG 1/17 20.40 26.20
TOI: 8AM
POI: ISABELA
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 8hrs E
CCR INITIAL DX: DIET: NPO 1/12/20 straw clear 1.010 6.0 - - - normal - + - - 2 0 0 0 1
AISLES LEFT
IVF: PNSS 1L X 8 HRS
AL-L NITRAT
INITIAL DX: DIET: NPO UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
E
Leukocyte RBC WBC EPITH HYALI BACTERIA
debridement
POI: TUG. CITY 1/15/2020 14.80 1.18 74.10 25.20
Inform ortho service
TRAUMA FEMALE A
PATIENT DIAGNOSIS MEDICATIONS DIAGNOSTICS
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x12hours E
TFA INITIAL DX: DIET: DAT with SAP 1/102020
th
output q shift
14 HOSPITAL DAY
PLAN:
Bev
MGH
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: D5LR 1LX 12HOUR E
TF-A INITIAL DX: DIET: May have Soft Diet Yellow Clear 1.030 6 - Trace Trace - - + - - 16 21 10 1 96
ANCILLARY:
EVICERATED BOWEL
SECONDARY TO MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
STABWOUND LEFT 1/14 9.2 111 0.34 74 17 7.9 0.5 0.2 239
BARRERO, JAYCEE ANUA LOWER QUADRANT
PLAN:
26/M MGH
CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL AST ALT TB TP A/G CEA
1/14 4.12
DOA: 01/12/20
PT % INR CONTROL APTT CONTROL
HISTORY:
TOI: 7AM
DOI: 1/12/2020
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1 L X 12 HRS E
TF-A INITIAL DX: DIET: DAT with SAP
CAPINLAC, ROMAN BASA CONTUSION
ANCILLARY: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
HEMATOMA, RIGHT
58/M
FRONTOTEMPORAL 1/15/20 10.8 169 0.46 73 17 8.8 0.1 0.8 212 81 30 365
MEDICATION
DOB: 11/20/1963 AREA SEC. TO FALL
Ampicillin- Sulbactam
1.5 g IV q8
DOA: 01/15/2020
Mannitol 150 cc q4
Ketorolac 30 mg q8 IV
CC: LOC CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
PRN for pain
1/15 133 3.24
NOI: FALL
PLAN: 1/16 13.30 5.04 1.37 1.29 3.12
TOI: 5PM Increase mannitol PT % INR CONTROL APTT CONTROL
120ccq4 1/15/20 13.50 27.10
DOI: 1/12/20 Continue Medications
POI: ISABELA
TRAUMA FEMALE B
IVF: PNSS 1L 8hours UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRITE Leukocyte RBC WBC EPITH HYALI BACTERIA
TF-B INITIAL DX: DIET: DAT with SAP DY Hazy 1.010 7.5 - TRACE + - - - - 24 5 1 1
-
PNEUMOHEMOTHOR
AX SECONDARY TO ANCILLARY: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
LIZARDO, EDUARDO JR. UBERITA STABWOUND 1/07/20 14.3 115 0.35 64.5 14.7 10.0 10.4 0.4 360 90 30 329
ANTERIOR CHEST 6TH MEDICATION: 1/9/2020 16.2 131 0.40 70 13.7 13.3 2.6 0.4 256 88 29 328
22/M 1. Celecoxib
INTERCOSTAL SPACE 1/15/20 17.6 132 0.39 65.4 19.2 7.2 7.5 0.7 474 86 29 336
TOI: 11PM
DOI: 11/07/20
POST OP DAY 10
bincey
IVF: PNSS 1L 12hours UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRITE Leukocyte RBC WBC EPITH HYALI BACTERIA
TF-B INITIAL DX: DIET: DAT with SAP DY Hazy 1.010 7.5 - TRACE + - - - - 24 5 1 1
-
PLAN:
HISTORY: Start Ascorbic acid
500mg OD
NOI: VA Shift mannitol 100cc q8
WOF neurodeterioration
TOI: 12am
DOI: 11/20//20
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 16hrs E
TM-B INITIAL DX: DIET: DM DIET 1/10/2020
IVF: PNSS 1L X 8 HRS UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
Leukocyte RBC WBC EPITH HYALI BACTERIA
TF-B INITIAL DX: DIET: DAT
E
MEDICATION 1/14/20 10 148 0.43 73.2 19.7 5.8 1 0.3 185 84 29 342
DOB: 06/6/1980 CONTUSION Ampicillin-Sulbactam
HEMATOMA, RIGHT 1.5 g IV q8
DOA: 01/14/2020
FRONTOTEMPOROPA Ketorolac 30mg IV PRN
RIETAL for pain
CC: SEVERE HEADACHE
Mannitol 150 cc IV then CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
decrease to 100cc q4
1/14/20 131.1 4.47
NOI: MAULING with BP precaution
1/18 93 130.80 3.95
POI: AMULUNG
ISOLATION
GS1
IVF: PNSS 1L X 8 HRS UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
Leukocyte RBC WBC EPITH HYALI BACTERIA
GS-1 INITIAL DX: DIET: Soft Diet E
Light
11/14/20 Clear 1.020 6.0 - - - normal - - - - 0 0 0 0 1
Yellow
TOMAS, VIRGILIO PILAR ACUTE APPENDICITIS ANCILLARY
MEDICATION
74/M Cefoxitin 1g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Metronidazole 500mg 1/14/20 18 125 0.36 93.4 4.5 1.8 0.2 0.1 273 90 31 346
DOB: 03/28/1945
IV q8
DOA: 01/14/20 Omeprazole 40 mg IV
OD
CC:RLQ PAIN
PLAN: CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
6th HOSPITAL DAY MGH
1/14/20 136.80 3.82
IVF: D5LR 1L X 8 HRS UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
Leukocyte RBC WBC EPITH HYALI BACTERIA
GS-1 INITIAL DX: DIET: SOFT DIET with E
LY Clear 1.015 7 - - - - - - + 0-2 1-3 +
SAP -
LACUBAN, LUZVIMINDA ACOM ACUTE APPENDICITIS ANCILLARY
MEDICATION
54/M CEFOXITIN 1G/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
PLAN:
Refer to OB for further PT % INR CONTROL APTT CONTROL
evaluation and
management
OVERFLOW
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PLRS1L x 8HRS E
OF INITIAL DX: DIET: DAT 1/13 LY Hazy 1.030 6 - - - - - - - - 4 1
MONITOR VS q4 and
record
DOB: DEC 21 1970 Monitor input and
output qshift
CHEM CREA BUN AMY LIPA NA K CL FAS CHO TRIG HDL LDL ALT TB TP A/ CEA
DOA: 1/13/2020 ISTRY SE GLU OLE LY G
PLAN:
For excision of
CC: NECK MASS
mass on tuesday PT % INR CONTROL APTT CONTROL
HISTORY:
luis
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PLRS1L x 8HRS E
OF INITIAL DX: DIET: DAT 1/13 LY Hazy 1.030 6 - - - - - - - - 4 1
MONITOR VS q4 and
record
DOB: NOV 20 1961 Monitor input and
output qshift
CHEMISTRY CREA BUN AMY LIPAS NA K C FAS GLU CHOOLE TRIGLY HDL AST ALT AL TP A/G CEA
DOA: 1/16/2020 E L P
PLAN: 1/19 78 139 3.51
Still for E appendectomy
1/16 25 32
ffup IM referal for CP
CC: RUQ PAIN evaluation PT % INR CONTROL APTT CONTROL
1:40pm: S/P
appendectomy
4th hospital day
URO
IVF: D5LR X 8 HRS
URO INITIAL DX: DIET: NPO UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
Leukocyte RBC WBC EPITH HYALI BACTERIA
E
Light
1/16/2020 Cloudy 1.010 9 - - - - - - - 0-1 2-4 - +++
CASTILLO, EDIMAR CARMELO INDIRECT INGUINAL ANCILLARY: yello ++
4TH HOSPITAL STAY PLAN: CHEMISTRY CREA BUN AMY LIPAS NA K CL FAS CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
E GLU
1/16/2020 135 4.53
for E mesh hemioplasty
WOF severe abdominal
pain, vomitting
PT INR % Control PTT Control
GS3
ANCILLARY:
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
E
GATCHALIAN, CHRISTYN KHEY INTRACRANIAL MASS MEDICATION: ½/2020 LY CLEAR 1.030 6.5 - - + - - + _ _ 7 25 29 0 446
ADIAZ INTRAVENTRICULAR 1. Cefuroxime
150mg/IV
17/M
2. Ranitidine 1
amp CHEMISTRY CREA BUN AMY LIPA NA K CL M CA ALBUM GLOBULIN AST ALT TB TP A/G CEA
3. Dexamethaso SE G IN
1/06/20 70.60 139 3.41 92
DOB:12/15/2002 ne 4g/IV
4. paracetamol PT % INR CONTROL APTT CONTROL
MONITOR VS q4 and
record
CC: abdominal pain Monitor input and
output qshift
ANCILLARY:
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
E
MALLO VICTORIA MABBORANG CALCULOUS MEDICATION: 1/102020 Y Clear 1.020 6 - - - - - - - - 3 7 7 1 19
CHOLECYSTITIS 5. Cefuroxime
72/M
150mg/IV
6. Omeprazole
40mg/IV
DOB: 2/8/1947 7. Ketorolac
30mg/IV CHEMISTRY CREA ALP AMY LIPAS NA K C M CA ALBUMIN GLOBULIN AST ALT TB DB IB HBsAG Anti-HBs
E L G
DOA: 01/10/2020 8. KCL drip
1/10/20 120 48 40 12 3.3 23 15 43. 27.6 15.7 NR 110.7
9. Tramadol 7 2 40 0
50mg/IV 1/11/20 4.1
6
10. HNBB 1
CC: abdominal pain AMP/IV PT INR % Control PTT Control
ANCILLARY:
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
E
ALLAG, GERARDO ACEBEDO ELECTROLYTE MEDICATION:
IMBALANCE 11. Human
69/M SECONDARY TP POOR albumin 1 vial
ORAL INTAKE, T/C 12. tramadol CHEMISTRY CREA LDH AMY LIPASE NA K CA MG CL ALB GLOBULIN A/G TP TB DB IB CEA Anti-HBs
INTRAABDOMINAL 50mg/IV PRN
DOB: 06/10/50 MASS 1/16 486