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GENERAL SURGERY: TEAM I

DR. TAMANI/LINGAN/AGUISANDA/BACULI/CASCO/ BULUSAN/ padilla/soriano/ravivarma/raveendran/nagui/shanmugam/navalta/felix

JANUARY 20, 2020

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

run for 15 PT INR % Control PTT Control


HISTORY: gtts/min
1/11/20 13.20 1.06 90.4 34.3
NOI: VA
MONITOR VS q4 and
TOI: 6:30AM record
Monitor input and
POI: PENABLANCA, CAGAYAN output q shift

DOI: 01/06/20 PLAN:


Dailly CTT care
14th hospital day Pls Facilitate Chest UTZ
Continue incentive
spirometry`

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

2nd hospital day 50mg/IV


1/18 136 4.48
4. Tranexamic
acid
PT INR % Control PTT Control
135/mg/IV
5. Vitamin K
qg/IV

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

ARBOLANTE, MICHEAL GAMATA MULTIPLE ANCILLARY:


PHYSICALINJURY
27/M SECONDARY TO MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
VEHICULAR 6. Ampicillin 1/18 10.7 130 0.41 79 12.8 6.8 0.8 0.6 329
DOB:04/29/1992
ACCIDENT, CEREBRAL sulbactam
DOA: 01/18/20 CONCUSSION TO 1g/IV q8
CONSIDER VASCULAR 7. ketorolac CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

CC: VEHICULAR ACCIDENT INJURY 30mg/IV


1/18 85 138 4.57
8. Omeprazole
NOI: VEHICULAR ACCIDENT 40mg/IV
PT INR % Control PTT Control

TOI: 6PM MONITOR VS q4 and 1/18 15.20 39.20


record
DOI:1/18/20 Monitor input and
output q shift
POI: TUAO CAGAYAN
PLAN:
for neck CT scan
2nd hospital day
(1/26/20)

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

NOI: STAB WOUND PLAN: PT % INR CONTROL APTT CONTROL

MGH
TOI: 11PM

POI: APARRI CAGAYAN

DOI: 01/11/2020

9th Hospital day

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

DOB: 10/24/2019 SKULL FRACTURE Sulbactam 162.5g


FRONTAL RIGHT IV q6
DOA: 01/20/2020 5. Paracetamol
90mg/IV
CC: VEHICULAR ACCIDENT 6. Ranitidine CHEMISTRY CREA BUN AMY LIP NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
ASE
6.5mg/IV 1/20/20 135.50 4.41
7. Ampicillin
HISTORY: Sulbactam
170mg/IV PT % INR CONTROL APTT CONTROL
NOI: VA
MONITOR VS q4 and
record
TOI: 8PM

POI: CABAGAN ISABELA PLAN:


Carry out pedia notes
DOI: 01/20/2020 WOF neurodegeneration
Continue Antibiotics
1ST Hospital day
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: DAT with SAP 1/17 LY CLEAR 1.010 6.5 - - - - - + - - 0-2 0-1 0 0 +

GALLARDO, NICK ALAGANO MULTIPLE PHYSICAL


ANCILLARY: CTT output
INJURY SECONDARY
41/M 400cc
TO VEHICULAR CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT, TRIPOD MEDICATION: 1/17 17.2 119 0.38 89.2 5.7 4.7 0.1 0.3 281 63 20 317
DOB:05/24/78
FRACTURE, RIGHT 8. Ampicillin-
DOA: 01/16/2020 Sulbactam 1.5g IV
q8
CC: VEHICULAR ACCIDENT 9. omeprazole
40mg/IV
10. Ketorolac 30mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
HISTORY: MONITOR VS q4 and
record
NOI: VA
PLAN: PT % INR CONTROL APTT CONTROL
TOI: 10PM
For Facial CT scan with
3D enhancement
POI: ENRILE CAGAYAN

DOI: 01/16/2020

4TH Hospital day

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

ARBOLANTE, MICHEAL GAMATA MULTIPLE ANCILLARY:


PHYSICALINJURY
27/M SECONDARY TO MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
VEHICULAR 9. Ampicillin 1/18 10.7 130 0.41 79 12.8 6.8 0.8 0.6 329
DOB:04/29/1992
ACCIDENT, CEREBRAL sulbactam
DOA: 01/18/20 CONCUSSION TO 1g/IV q8
CONSIDER VASCULAR 10. ketorolac CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

CC: VEHICULAR ACCIDENT INJURY 30mg/IV


1/18 85 138 4.57
11. Omeprazole
NOI: VEHICULAR ACCIDENT 40mg/IV
PT INR % Control PTT Control

TOI: 6PM MONITOR VS q4 and 1/18 15.20 39.20


record
DOI:1/18/20 Monitor input and
output q shift
POI: TUAO CAGAYAN
PLAN: Still for neck CT
scan
1ST hospital day
daily wound care

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

ACUTE EPIDURAL ANCILLARY:


HEMATOMA, RIGHT MEDICATION: Ampicillin-
LAURETA, REYNARD CALMA FRONTOTEMPOROPA Sulbactam 1.5g/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
RIETAL LEFT; Omeprazole 40mg/IV 1/14/ 20 10.9 107 0.31 82 9.7 5.8 2.2 0.3 231 93 33 351
FRONTOTEMPOROPA Tranexamic Acid
RIETAL; SKULL 500mg/IV
FRACTURE LEFT Ketorolac 30mg/IV
DOB:Oct 18 1999 FRONTAL;
NEUROCEPHALOUS
CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOA: 01/10/20 MONITOR VS q4 and
record 1/14/20 135.1 2.97
CC: VA Monitor input and
1/13/20 138.30 3.57
output q shift
10th HOSPITAL DAY
PLAN: PT INR % Control PTT Control

Daily wound care


Bincey continue meds 1/13//20 13.30 30.30
decrease manitol to 75cc
q8 x 3 cycles then d/c
Facilitate Correction of
potassium

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

DOA: 01/10/20 MONITOR VS q4 and


record
CC: Monitor input and CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

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

TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
MASCARINAS, CLARENCE JESSIE ACUTE EPIDURAL 1/18 LY CLEAR 1.030 6.5 - - ++ - - + - - 8-10 2-3 - - +
CORTEZ HEMATOMA, ANCILLARY:
FRONTOTEMPOROPA
6/M RIETAL RIGHT MEDICATION:
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
SECONDARY TO FALL Ampicillin-Sulbactam
DOB: 05/8/2013 1.5g TIV q8 1/18 7.6 103 0.30 62 31 5.4 0.4 0.7 344 80 28 344

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

TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
LAWAGAN, BRYAN GARRO MULTIPLE PHYSICAL 1/18 LY CLEAR 1.030 6.5 - - ++ - - + - - 8-10 2-3 - - +

INJURY SECONDARY ANCILLARY:


20/M TO VA, MINIMAL
ACUTE SUBDURAL MEDICATION:
DOB: 05/11/1999 Ceftriaxone 1gm/IV
HEMATOMA RIGHT CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
PARIETAL LINEAR Omeprazole 40mg/IV
DOA: 01/18/20 1/18 10 102 0.31 72 19 7 0.1 0.3 301 90 30 330
SKULL FRACTURE, Ascorbic acid 40mg/IV
CC: VEHICULAR ACCIDENT RIGHT PARIETAL, Mannitol 100cc/IV
PNEUMOCEPHALUS, Gentamycin 240mg/IV
NOI: VA OPEN FRACTURE LEG Pen G 5 milli units
LEFT CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
TOI: 8AM Monitor VS q2 and ISTRY SE MIN LIN G
record 1/18 139 4.49
POI: TUMAUINI ISABELA Monitor I & O qshift and /20

record PT INR % Control PTT Control


DOI: 1/18/20 PLAN:
Repeat CBC, Na, K 1/18/2020 14 27
2nd HOSPITAL DAY Continue medical
management
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

ANCILLARY: S/D Nirpid ½


L x 24hours
UMAYAM, CARLO MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

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

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
MEDALLA. ERICKSON ACUTE SUBDURAL MEDICATION:
HEMATOMA, LEFT Ampicilin-Sulabctam
18/M PARIETAL AREA 1.5g IV q8
SECONDARY TO Omeprazole 40mg/IV
DOB: 11/18-2001 Mannitol/100cc/IV
VEHICULAR CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

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

CC: VEHICULAR ACCIDENT PLAN:


WOF
NOI: VEHICULAR ACCIDENT neurodegeneration CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

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

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: Soft diet with SAP E
SARDON, NESTOR CAMAGON MULTIPE PHYSICAL
INJURY SECONDARY MEDICATION:
46/M TO VEHICULAR Mannitol 150cc/IV
ACCIDENT, Diphenhydramine
DOB: 8/16/73
CONTUSION 50mg/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

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

TEMPOROPARIETAL +10meqs KCL


CC: VEHICULAR ACCIDENT ACUTE EPIDURAL
HEMATOMA LEFT PLAN:
NOI: VEHICULAR ACCIDENT PARIETO-OCCIPITAL Decrease mannitol CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

TRAUMATIC Start N-acetylcysteine


TOI: 10PM 1/20/20 3.52
SUBARACHNOID hook to 02 support
1/19/20 136.40 2.88
HEMORRHAGE may transfer to surgery
DOI: 1/16/20
ward
PT INR % Control PTT Control
POI: STA TERESITA

4TH Hospital stay

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
1/102020
GUILLERMO RODNEL OLORAZA GUNSHOT WOUND, MEDICATION:
POINT OF ENTRY Ampicilin-Sulabctam
37/M LATERAL LEG RIGHT, 1.5g IV q8
POINT OF EXIT Mannitol 150 cc IV q4 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 7/24/82 with BP precaution
MEDIAL LEG RIGHT 1/20 17.2 134 0.38 82 12 4.9 0.2 0.3 281
Ketorolac 30 mg/IV q8
DOA: 01/20/20 PRN for pain
Kcl drip: 900cc PNSS +
CC: GUNSHOT WOUND
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
NOI: GUN SHOT WOUND cycles
1/20 135 4.11

TOI: 12AM PLAN:


Start ascorbic acid
DOI: 1/20/20 500mg tab PT INR % Control PTT Control
Start tranexamic acid
1STHospital stay 1g/IV
D/C clindamycin
Start Ampicillin
sulbactam
Facilitate chest XrAy
TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
VILLARAO VINCE ARENZ RAMOS GUNSHOT WOUND, MEDICATION: 1/102020

POINT OF ENTRY Ampicilin-Sulabctam


13/M RIGHT UPPER 1.5g IV q8
GLUTEUS, POINT OF Mannitol 150 cc IV q4
DOB: 3/5/2005 with BP precaution
EXIT NONE CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Ketorolac 30 mg/IV q8 1/20 189 132 0.38 84 11 3.7 0.2 0.3 359
DOA: 01/20/20
PRN for pain
CC: GUNSHOT WOUND Kcl drip: 900cc PNSS +
10 meqs Kcl x 1 hr x 2
NOI: GUN SHOT WOUND cycles CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

TOI: 1AM 1/20 138 4.11


PLAN:
DAILY WOUND CARE
DOI: 1/20/20 continue IV antibiotics
PT INR % Control PTT Control
1STHospital stay

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: Low fat low salt E
DOMINGO NORMAN MULTIPLE PHYSICAL diet 1/20/20 YELLOW HAZY 1.020 6.5 - ++ + - - + - - 5-8 3-5 FEW

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

1/14/20 136.40 3.71


DOI: 1/20/20 PLAN:
1/18/20 136 3.49
Insert IFC and NGT
1STHospital stay
Secure 2 units PRBC
PT INR % Control PTT Control

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: Low fat low salt E
BALANAY, ERNESTO BIGGAYAN CONTUSION diet 1/102020

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

6thHospital stay Decrease mannitol to


150cc/IV q6 PT INR % Control PTT Control

Continue medications

TM-B INITIAL DX: IVF: D5LRS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
ESTABILLO, ARIEL CABANSAG MULTIPLE PHYSICAL
INJURY SECONDARY MEDICATION: Mannitol
19/M TO VEHICULAR 150cc/IV
ACCIDENT. MINIMAL Ceftriaxone 2g/IV
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 01/16/2001
ACUTE SUBDURAL Omeprazole 40mg/IV 1/18/20 20.8 138 0.40 89.7 3.6 6.6 0.0 0.1 287 92 32 342

DOA: 01/18/2020 HEMATOMA, RIGHT Ketorolac 30mg/IV


FRONTAL SKULL Ascorbic acid 500mg/
CC: INGESTION OF ZONROX FRACTURE FRONTAL tab
AREA B complex tab
2nd 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
PLAN: 1/18 135 3.85
Continue Medications /20

WOF nuerodegeneration PT INR % Control PTT Control

1/18/20 15.50 40.10

TM B INITIAL DIAGNOSIS IVF: D5LRS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: SOFT DIET WITH E
SORBANO JOHNNY URANI EPIDURAL SAP
42/M HEMATOMA RIGHT,
FRONTOTEMPOROPA MEDICATION: Mannitol CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 4-7-1977 RIETAL 150cc/IV 1/18/20 20.8 138 0.40 89.7 3.6 6.6 0.0 0.1 287 92 32 342
INTRACEREBRAL Ceftriaxone 2g/IV
DOA:1/15/20
HEMATOMA RIGHT Omeprazole 40mg/IV
CC: Vehicular Accident FRONTAL Ketorolac 30mg/IV
SECONDARY TO Ascorbic acid 500mg/
NOI:VA VEHICULAR tab
ACCIDENT B complex tab
TOI:3PM
PLAN:
DOI:1/15/20 Facilitate referal to
OPTHA
POI: TUMAUINI
Decrease Mannitol
120cc/IV q6
5th HOSPITAL STAY
Daily wound care

TM-B INITIAL DX: IVF: D5LRS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: General liquid diet E
SUAREZ, ERNIE BAYONA CAUSTIC INGESTION
(ZONROX) MEDICATION:
50/M
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 06/27/69 1/14/20 25.1 128 0.38 88.2 3.7 8.7 0.1 0.2 230 90 31 338
PLAN:
DOA: 01/15/2020 MGH

CC: INGESTION OF ZONROX

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

PT INR % Control PTT Control

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

Irepeat ECG at 8pm


TOI: 3PM daily hygien 1/18 68.40 138.40 3.75 13 NEGATIVE

DOI: 1/18/20 PT INR % Control PTT Control

POI: TUGUEGARAO CITY

2nd Hospital stay

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

NOI: FALL PLAN:


CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
MGH ISTRY SE MIN LIN G
TOI: 12:30PM
1/16 138

DOI: 1/16/20
PT INR % Control PTT Control
POI: PENABLANCA
1/16 16 30.50
4TH HOSPITAL STAY

CRITICAL CARE ROOM


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: NPO

MULTIPLE PHYSICAL ANCILLARY:


INJURY SECONDARY
AGRIAM, MARY ROSE SOSA TO VEHICULAR MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT,
42/F 1/18/20 19.6 120 0.34 91.8 3.8 4.3 0 0.1 161
TRAUMATIC
DOB:12/18/1977 SUBARACHNOID MONITOR VS q2 and
HEMORRHAGE record CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

DOA: Jan 18 2020 SECONDARY TO Monitor input and


59 145 3.88
VEHICULAR output qshift
CC: Vehicular Accident ACCIDENT PT % INR CONTROL APTT CONTROL
1/18/2020 18.70 35.60
PLAN:
NOI: Vehicular accident Continue Meds
prognosticated
TOI: 3pm Secure form for DNR

DOI: 1/18/20
POI: CLAVERIA, CAGAYAN

2ND HOSPITAL DAY

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

3RD HOSPITAL STAY


Luis

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

MULTIPLE GUNSHOT ANCILLARY:


WOUND: POINT OF
ASIA, ROGELIO PESCADOR ENTRY 1. ANTERIOR MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
CHEST 2ND
46/M 1/12/20 17.4 137 0.40 82 8.3 5.5 3.7 0.5 300 92 31 339
INTERCOSTAL SPACE, ampicillin-sulbactam
MID CLAVICULAR 1.5g/IV
LINE RIGHT; POINT Omeprazole/ 40mg/IV
OF EXIT 1: NONE; ketorolac 30mg/IV
POINT OF ENTRY Tramadol 50mg/ml CHEMISTRY CREA BUN AMY LIPA NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOB: 2:LEFT CHEEK; POINT SE
OF EXIT 2: NONE; MONITOR VS q2 and 1/13/20 111 142.61 98.64
DOA: JAN 12 2020 POINT OF ENTRY 3: record 1/12/2020 140.10 3.90
LEFT DELTOID; POINT Monitor input and
CC: GUN SHOT WOUND
OF EXIT; LEFT UPPER output qshift PT INR % Control PTT Control

8th hospital day BACK, POST AXILLARY


LINE; POINT OF PLAN: 1/12/2020 11.40 19.70
Varma
ENTRY 4; LEFT MGH
MEDIAL FOREARM;
POINT OF EXIT 4;
NONE
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1Lx KVO E
CCR INITIAL DX: DIET: DAT c SAP 1/10/2020

MULTIPLE STAB ANCILLARY:


WOUND 1) 5TH
DOQUES, MABINI JR ESCOBAR INTERCOSTAL SPACE CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
PARASTERNAL AREA, MEDICATION: 1/06/20 23.1 93 0.28 72.2 13.4 7.1 6.9 0.4 1049 82 27 333
25/M
RIGHT 2) 10TH 1/12/20 17.5 99 0.30 69.2 15.2 6.9 8.2 0.5 951 84 27 342
1/15/20 17.3 106 0.33 67.4 14.3 7.5 10.3 0.5 925 85 27 320
INTERCOSTAL SPACE
1/19/20 14.8 118 0.36 62 15 8.2 14.1 0.5 667 82 27 324
MAXILLARY LINE PLAN:
For VATS
Ffup availability of 2 CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOB:11/ 14/ 1994 units PRBC 1/06/20 133.10 4.57
Continue incentive
DOA: 12/ 26/ 2019 spirometry 1/12/20 61.60 137 4.26

1/19/20 62 136 3.96


CC: stab wound
PT INR % Control PTT Control
26th hospital stay
1/12/20 12.40 31.60
bincey
1/19/20 13.20 54.50

IVF: PNSS 1L X 8 HRS NITRAT


UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT E
CCR INITIAL DX:
ANCILLARY:
PAET, REYNALDO JR SALVADOR MULTIPLE PHYSICAL
INJURY SEC. TO VA MEDICATION
32/M Ampicillin- Sulbactam
MINIMAL ACUTE 1.5 g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 07/20/1987 SUBDURAL 1/15/20 25.5 140 0.40 83.5 10.5 5.2 0.2 0.6 422 85 30 353
Mannitol 100cc IV q4
HEMATOMA, RIGHT 1/19 17.7 112 0.33 64 19 12 2.9 0.9 399 86 29 339
DOA: 01/15/2020 Omeprazole 40 mg IV
TEMPORAL OD
CC: LOC TRAUMATIC Ketorolac 30mg IV PRN
SUBARACHNOID for pain q6
NOI: VA HEMORRHAGE CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
PLAN:
1/15 138.40 4.01
TOI: 12 AM /20
decrease mannitol to 1/19 134.70 4.19
DOI: 1/15/20 100cc/IV then D/C
Continue present PT INR % Control PTT Control
POI: BAGGAO medications
1/15/20 13.40 1.07 87.9 21.4
5th HOSPITAL DAY

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

AGUILLON, CHRISTIAN DAVE MULTIPLE PHYSICAL ANCILLARY:


CASTRO INJURY SEC. TO VA
MEDICATION:
20/M OPEN FRACTURE, Ampicillin- Sulbactam
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
LEFT LEG 1.5g q8
DOB: 07/17/20 Ketorolac 30mg IV q8 1/15/20 19.6 132 0.39 83.1 9.1 7.5 0.1 0.2 367 87 29 335

PRN for pain


DOA: 01/14/20 Omeprazole 40mg IV
q24
CC: GROSS DEFORMITY ON LEFT
Cefoxitin 1g IV q8
LEG
Gentamycin 240mg IV x CHEMISTRY CREA BUN AMY LIPA NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
SE
NOI: VA 7 days
1/15/20 140.40 3.43

TOI: 8:30PM PLAN:


GS/NSS cleared
DOI: 1/14/20 may proceed with “E” PT INR % Control PTT Control

debridement
POI: TUG. CITY 1/15/2020 14.80 1.18 74.10 25.20
Inform ortho service

6TH HOSPITAL DAY

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

MULTIPLE PHYSICAL ANCILLARY:


INJURY SECONDARY
AGLUGUB, FELICISIMO GARCIA TO VEHICULAR MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; BLUNT 1. Tramadol 50 1/06/20 12.3 123 0.39 75.4 13.8 10.3 0.2 0.3 241 87 28 319
72/M
CHEST TRAUMA, mg IV q8 1/10/20 14.2 125 0.38 87.5 6.1 6.2 0.0 0.2 275 86 28 330

MULTIPLE RIB 2. Celecoxib


FRACTURE 4TH-5TH 200mg cap
DOB: 03/24/47 RIBS, LEFT SPINAL BID prn for
CORD INJURY pain CHEMISTRY CREA BUN AMY LIPASE NA K UREA FAST GLU CHOLE TRIGLY HDL LDL ALT TB TP A/G CEA
DOA: 01/06/20 3. Salbu + iprat
neb q6 1/06/20 138 4.18 5.00

1/09/20 5.4 3.87 0.82 1.49 2.01


MONITOR VS q4 and
CC: VEHICULAR ACCIDENT record 1/10/20 137.20 4.08

Monitor input and PT % INR CONTROL APTT CONTROL

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

DOB: Jun 13 1993 1/12 84 140 4.29 37 49

1/14 4.12
DOA: 01/12/20
PT % INR CONTROL APTT CONTROL

CC: Stab wound

HISTORY:

NOI: Stab wound

TOI: 7AM

POI: MACUNACON, ISABELA

DOI: 1/12/2020

8th HOSPITAL DAY

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

5th HOSPITAL DAY

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

MIDCLAVICULAR LINE 200mg/cap, 1


LEFT cap BID PRN
for pain
DOB:09/08/97
2. Salbutamol
DOA: 01/09/20 neb q6
3. Ampicillin-
Sulbactam CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
1.5g IV q8
1/07/20 134.30 4.16
CC: STAB WOUND
1/15/20 136.10 4.15

PLAN: PT % INR CONTROL APTT CONTROL


HISTORY: For Chest XRAY
CTT care
NOI: STAB WOUND

TOI: 11PM

POI: LASAM, CAGAYAN

DOI: 11/07/20

11th HOSPITAL DAY

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
-

MULTIPLE PHYSICAL ANCILLARY:


INJURY SECONDARY
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
CORPUZ, JERICO MACAPAGAL TO VEHICULAR MEDICATION: 1/20/20 10 121 0.36 64 26 6.7 2.3 0.5 553 84 28 334
ACCIDENT, ACUTE 4. Ceftriaxone
16/M
EPIDURAL 1g/IV
HEMATOMA 5. Ketorolac
PARIETOOCCIPITAL 3mg/IV
DOB:09/17/2003 AREA RIGHT; 6. Mannitol CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA

PNEUMOCEPHALUS 100cc/IV q8 1/20/20 136.70 3.68


DOA: 01/20/20 LINEAR SKULL 7. Paracetamol
PT % INR CONTROL APTT CONTROL
FRACTURE 1g/IV
8. Tranexamic
Acid1g/IV
CC: Vehicular accident

PLAN:
HISTORY: Start Ascorbic acid
500mg OD
NOI: VA Shift mannitol 100cc q8
WOF neurodeterioration
TOI: 12am

POI: Mallig Isabela

DOI: 11/20//20

1st HOSPITAL DAY

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

MULTIPLE STAB ANCILLARY:


WOUND 8TH
ARNEDO, SEVERINO GALARCE INTERCOSTALS MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
SPACE, RIGHT. LEFT Human Albumin, 1 Vial 1/09/20 11.3 96 0.28 88 6.8 4.3 0.6 0.3 345 83 29 347
57/M
UPPER QUADRANT. to run for 6hours q12
POSTERIOR ARM,
LEFT MONITOR VS q2 and
CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
record
Monitor input and 1/09/20 3.63 142.61 98.64
DOB:07/26/1967 output qshift 1/12/2020 4.11

1/14/2020 21 26.30 47 0.8


DOA: PLAN: 0
Wound Flushing q12 PT % INR CONTROL APTT CONTROL
CC: Stab wound Encourage ambulation
Give paracetamol 1g/IV
Apply ice pack to Left
Jesserene arm

IVF: PNSS 1Lx 8 hrs NITRAT


TF-B INITIAL DX: DIET: OF feeding
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
E
Leukocyte RBC WBC EPITH HYALI BACTERIA

JARA, JUDY JR SEATRIZ T/C BRAIN ABSCESS,


ANCILLARY:
RIGHT
34/M CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
FRONTOTEMPORAL
MEDICATION 1/14/20 9.7 159 0.46 71.9 19.6 7.2 1.1 0.2 322 85 30 348
DOB: 04/29/1985 Ceftriaxone 2g IV q12
S/P E' CRANIECTOMY,
RIGHT EVACUATION Vancomycin 1g IV q12
DOA: 01/14/20
OF HEMATOMA FOR Ketorolac 30mg IV q8
PRN for pain
CC: GENERALIZD BODY WEAKNESS ACUTE EPIDURAL
HEMATOMA, CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
TEMPORO-PARIETAL, PLAN:
Continue oral feeding 1/15/20 75.20 136.8 4.08 93
(+) HEADACHE RIGHT WITH .6
DEPRESSED SKULL Continue medications
(+) DIZZINESS WOF any problems
FRACTURE , RIGHT PT % INR CONTROL APTT CONTROL

FRONTOTEMPOROPA 1/14/20 14.80 1.17 75.80 25.80


(+) N/V
RIETAL SEC. TO VA
ESR: 24mm/hr
6th Hospital stay

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

DANAO, PAULO MARTIN MULTIPLE PHYSICAL


INJURY SEC. TO ANCILLARY:
39/M MAULING CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

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

TOI: 7PM PLAN: PT % INR CONTROL APTT CONTROL

MGH 1/14/20 12.70 97 1.02 25


DOI: 1/09/20

POI: AMULUNG

6TH hospital day

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

PT % INR CONTROL APTT CONTROL

1/14/20 12.90 94.20 1.03 31.50

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

Metronidazole 500mg/IV 1/16 15 114 0.36 66 23 5.3 5.2 0.3 278


DOB: 08/3.65
Omeprazole 40mg/IV
DOA: 01/16/2020
MONITOR: VS q4 and
CC: RUQ PAIN record
Monitor I&Oqshift and CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
4TH HOSPITAL DAY record
1/16 142.30 3.71

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

PAROTID MASS ANCILLARY:


MACANAN, NOEL VINASOY MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
1.
49/F 1/13 10 156 0.48 59 28 4.4 7.2 0.6 279

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:

7th hospital day

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

ACUTE APPENDICITIS ANCILLARY:


BAJET BENJAMIN DE LEON MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
2.
58/F 1/16 13.1 148 0.43 85 8.8 3.4 1.5 0.4 246

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 ++

HERNIA, LEFT MEDICATION


34/M INCARCERATED Ampicillin-Sulbactam 1.5
g IV q8
DOB: 04/17/85 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Ketorolac 30mg IV PRN 1/16/2020 11 136 0.40 90 5.9 2.8 0.3 0.3 266
DOA: 01/16/2020
for pain
Omeprazole 40mg IV OD
CC: SCROTAL MASS

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

CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh


IVF: PNSS 1L x12hrs
GS-3 INITIAL DX: DIET: DAT with SAP 1/16/20 17 123 0.37 67 20 10 2 0.3 297 89 30 332

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

DOA: 01/02/2020 300mg/IV

MONITOR VS q4 and
record
CC: abdominal pain Monitor input and
output qshift

18th hospital stay PLAN:


NEURO MGH
jesserene
Awaiting MRI result
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
IVF: D5LRS 1L x8hrs
GS-3 INITIAL DX: DIET: Soft Diet 1/10/20 32 105 0.31 84.1 6.3 9.4 0 0.2 250 77 26 337

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

MONITOR VS q4 and 1/10/20 14.20 38.40


10th hospital stay record
Monitor input and
output qshift
novi
PLAN:
MGH

CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh


IVF: D5LRS 1L x8hrs
GS-3 INITIAL DX: DIET: Soft Diet 1/14 7.9 113 0.34 78 9.5 8.1 3.4 0.3 400 83 28 335

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

MONITOR VS q4 and 1/14 132 4.23


DOA: 01/9/2020 record 1/11 1.1
Monitor input and
1/10 27 22.70 1.2 50 1.51
output qshift

CC: ABDOMINAL MASS PLAN: PT INR % Control PTT Control

ffup biopsy result

11th hospital stay


DISCHARGES
CARDENAS
ENRIQUEZ
CORPUZ
DANAO
ASIA
BALANAY
MALLO
VIRGILLO
AGLUGUB
UMAYAM
SUAREZ
TOMAS
BARRERO

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