Trauma Male A: General Surgery: Team I Dr. Tamani/Lingan/Aguisanda/Baculi/Casco/ Bulusan

GENERAL SURGERY: TEAM I
DR. TAMANI/LINGAN/AGUISANDA/BACULI/CASCO/ BULUSAN/ padilla/soriano/ravivarma/raveendran/nagui/shanmugam/navalta/felix
JANUARY 16, 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 1LxKVO E
TM-A INITIAL DX: DIET: DAT 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/B
DOA: 01/06/20 Ipratropium lin E Y G 2
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
HISTORY: gtts/min
NOI: VA PT INR % Control PTT Control
MONITOR VS q4 and
1/11/20 13.20 1.06 90.4 34.3
TOI: 6:30AM record
Monitor input and
POI: PENABLANCA, CAGAYAN output q shift
DOI: 01/06/20 PLAN:

Repeat CXR-PA
10th hospital day Continue Antibiotics
Novi
NITRAT
IVF: PNSS 15- E
TM-A INITIAL DX: 16UGTS/MIN
DIET: Diet for Age
CEREBRAL
CONCUSSION, ANCILLARY:
ANCHETA, JEFREY JR CASASIS PNEUMOCEPHALUS
LINEAR SKULL MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
7/M
FRACTURE, FRONTAL 1. 1/13 24.2 134 0.39 86.9 7.4 5.4 0.4 0.2 415
AREA SECONDARY TO
FALL
DOB: 11/26/2012
PLAN:
DOA: 01/13/2020 DAILY WOUND CARE CHEMI CRE BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
STRY A SE MIN LIN G
CONTINUE MEDS
1/13 138.80 3.71
MONITOR VSQ4
WOF
CC: FALL NEURODETERIORATION
PT INR % Control PTT Control

HISTORY:
NOI: FALL
TOI: 5PM
POI: GONZAGA CAGAYAN
DOI: 01/10/2020
6th Hospital stay

Varma
NITRAT
IVF: PNSS 1L x 8hr E
TM-A INITIAL DX: DIET: DAT with SAP 1/102020
MULTIPLE PHYSICAL ANCILLARY:

INJURY SECONDARY
DELA CRUZ, REYNALDO ORTIZ TO VEHICULAR MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; RIB 2. Ampicillin 1/9/20 8.6 132 0.40 69.2 21.1 8.2 1.2 0.3 256 88 29 332
50/M
FRACTURE, RIB LEFT sulbactam 1/15/20 8.2 134 0.40 61.5 24.4 7.0 6.5 0.6 257 89 30 335
SECONDARY TO 1g/IV q8
VEHICULAR 3. ketorolac
DOB:12/22/12 ACCIDENT 30mg/IV
4. tramadol CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOA: 01/02/20 50mg/IV
1/9/20 132.7 4.37
MONITOR VS q4 and
record PT INR % Control PTT Control
CC: VEHICULAR ACCIDENT Monitor input and
output q shift 12.70 28.40
PLAN:
HISTORY:
Continue incentive
spirometry
NOI: VA repeat CXR
WOF: DOB, Desaturation
TOI: 7pm Daily CTT care
POI: GATTARAN
DOI: 1/8/2020
14th hospital day
Tamil
NITRAT
IVF: PNSS 1L x KVO E
TM-A INITIAL DX: DIET: DAT
Pneumohemothorax
ANCILLARY: CTT output
left secondary to stab
CARDENAS, DARNLIE CASTRO 400cc
wound T10
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
33/M MEDICATION:
S/P CTT Left 1/11/20 16.0 68 0.20 88.2 5.7 5.8 0.1 0.2 150 65 22 342
1. Ampicillin- 1/14/2020 7.9 128 0.41 70.5 10.4 9.9 8.8 0.4 256 73 23 316
DOB:01/24/2020 Sulbactam 1.5g IV
q8
DOA: 01/11/2020 2. omeprazole
40mg/IV
CC: STAB WOUND 3. Ketorolac 30mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
MONITOR VS q4 and 1/11/20 133 4.39

record
HISTORY: 1/14/20 137 4.03
PLAN: PT % INR CONTROL APTT CONTROL

NOI: STAB WOUND
Continue incentive
spirometry
TOI: 11PM
For repeat CXR PA
POI: APARRI CAGAYAN continue present
management
DOI: 01/11/2020 Continue Medications
5th Hospital day
BEV
NITRAT
IVF: PNSS 1L x 8hrs E
TM-A INITIAL DX: DIET: NPO temporarily 1/17 LY CLEAR 1.010 6.5 - - - - - + - - 0-2 0-1 0 0 +
MULTIPLE PHYSICAL
ANCILLARY: CTT output
INJURY SECONDARY
GALLARDO, NICK ALAGANO 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
41/M
FRACTURE, RIGHT 4. Ampicillin-
DOB:05/24/78 Sulbactam 1.5g IV
q8
DOA: 01/16/2020 5. omeprazole
40mg/IV
CC: VEHICULAR ACCIDENT 6. Ketorolac 30mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
MONITOR VS q4 and
record
HISTORY:
NOI: VA WOF for
neurodeterioration, DOB
TOI: 10PM
POI: ENRILE CAGAYAN
DOI: 01/16/2020
1STh Hospital day
Trauma Male B
NITRAT
TM-B INITIAL DX: DIET: DAT with SAP

ENRIQUEZ, RICARDO GABRIEL TO VEHICULAR 5. CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; MULTIPLE
50/M
RIB FRACTURE, 3RD-
5TH RIB RIGHT PLAN:
Facilitate CXR at 8am
DOB: 07/25/1969 give celecoxib
200mg/tab CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOA: 01/16/2020 give epirisone5mg/tab
shift omeprazole IV to
oral 40mg/tab
shift ampicillin-
CC: VEHICULAR ACCIDENT sulbactam IV to oral
PT % INR CONTROL APTT CONTROL
HISTORY:
NOI: VA
TOI: 1AM
POI: SOLANA CAGAYAN
DOI: 01/16/20
1ST hospital day
NITRAT
IVF: PNSS 1L X KVO E
TM-B INITIAL DX: DIET: DAT with SAP 1/102020
MULTIPLE PHYSICAL
INJURY SECONDARY ANCILLARY:
PITA, SIMEON TO VEHICULAR MEDICATION: Ampicillin-
ACCIDENT , Sulbactam 1.5g/IV
1/09/20 6.7 69 0.20 73.0 13.9 6.7 6.1 0.3 152 93 32 340
CONTUSION Omeprazole 40mg/IV
HEMATOMA, LEFT Tranexamic Acid
FRONTOTEMPOROPA 500mg/IV
RIETAL, FEMORAL Ketorolac 30mg/IV
DOB:06/12/20
FRACTURE LEFT Cefoxitin 1g/IV
DOA: 01/07/20 Gentamycin 240mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
Mannitol 100c/IV
1/07/20 124.90 141.40 4.13
CC: VA
9th HOSPITAL DAY MONITOR VS q4 and
record
1/07/20 12.40 25.80
Monitor input and
Varma output q shift
PLAN:
Schedule for Chest CT
scan with contrast
2/22/2020
Ortho notes:
maintain on traction
for wound care
NITRAT
IVF: PNSS 1L X 8hr E
TM-B INITIAL DX: DIET: NPO

INJURIES SECONDARY MEDICATION:
BAYUGA,DEMY MACATUGGAL TO VEHICULAR CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACIDENT; BLUNT 1/15//2020 23 147 0.42 76 12 11 0.1 0.1 214
35/M
ABDOMINAL MONITOR VS q4 and 1/16/2020 19 144 0.41 80 8.3 11.6 0 0.2 208
TRAUMA record
Monitor input and
DOB:12/13/1984 output q shift
CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOA: 01/15/2020 PLAN:
Facilitate CXR-PA 1/16 138 3.90
CC: VA Facilitate repeat CBC
6hours post BT PT INR % Control PTT Control
NOI: VEHICULAR ACCIDENT WOF: DOB, desaturation,
bleeding, severe 1/14 13.60 24.10
TOI: 9PM abdominal pain
POI: ABULUG, CAGAYAN
DOI: 1/15/2020
1ST HOSPITAL DAY

NITRAT
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
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
4th 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
IVF: PNSS 1L x 8HOURS E
TM-B INITIAL DX: DIET: Dat with SAP 1/16/2020 Y Clear 1.025 - - - Trace - - - - - 0-2 0-2 +
ACUTE EPIDURAL ANCILLARY:

HEMATOMA,
GUZMAN, RUFINO BERGONIA TEMPOROPARIETAL MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
AREA LEFT 1. Ceftriaxone ig
70/M
SECONDARY TO FALL TIV q12
2. Ranitidine
25mg TIV q8
DOB: 10/24/1949 3. Paracetamol
250mg TIV q6
CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
DOA: 01/15/2020 PRN for pain ISTRY SE MIN LIN G
4. Mannitol 30cc 1/15 133 4.07
IV q8
CC: FALL
WOF:
Neurodegeneration
HISTORY:
Continue present
NOI: FALL management
TOI: 4PM
POI: TUMAUINI, ISABELA
DOI: 01/15/20
1ST HOSPITAL DAY
TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

E
PEREZ, JACK BARROGA MULTIPLE PHYSICAL ANCILLARY:
INJURY SEC TO VA TO
28/M CONSIDER LEFT LEG MEDICATION:
FRACTURE, Ampicillin-Sulbactam
DOB: 03/3/1991 1.5g TIV q8
LACERATED LEFT
FOOT Ketorolac 30 mg IV q8
DOA: 01/15/20 1/15/20 9.3 80 0.25 81.5 9.5 8.8 0.0 0.2 214 74 24 320
PRN for pain
CC: VA Omeprazole 40 mg TIV
q24
NOI: VA
Monitor VS q1 and
TOI: 12 AM record CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
Monitor I & O qshift and
POI: LALLO, CAGAYAN 1/15 142.7 3.47
record /20
PLAN:
DOI: 1/15/20 For repeat CBC 6hour
post BT
2nd HOSPITAL DAY May proceed with
1/15/2020 15.30 1.22 70.2 26.7

contemplated procedure
of ortho

DIET: DAT with SAP E
CABANERO, NARCISO PASCUA TRAUMATIC 1/102020
SUBARACHNOID MEDICATIONS:
69/M HEMORRHAGE Ampicillin- Sulbactam
SEC.TO VEHICULAR 1.5g/ IV q8
DOB: 04/21/1950
ACCIDENT Omeprazole 40mg IV OD CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOA: 01/13/20 Ketorolac 30 mg IV q8 x 1/14/20 25.1 128 0.38 88.2 3.7 8.7 0.1 0.2 230 90 31 338
3 doses
CC: Gentamycin 240mg/ IV
OD
NOI: VA
PLAN: CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
TOI: ISTRY SE MIN LIN G
WOF:
1/14 136.40 3.71
Neurodeterioration
DOI: /20
POI:
1ST HOSPITAL DAY
TM-B INITIAL DX: IVF: D5LRS 1L X 8 HRS NITRAT
DIET: NPO E
SUAREZ, ERNIE BAYONA CAUSTIC INGESTION
(ZONROX) MEDICATION:
50/M
DOB: 06/27/69
PLAN:
1/15 17 161 0.46 82 12 4 1.6 0.4 321
DOA: 01/15/2020 Refer back to
IM/GASTRO
CC: INGESTION OF ZONROX for EGD
Continue meds
2nd Hospital stay
CHEMISTRY CREA BUN AMY LIPAS NA K CL M CA ALBUMI GLOBULIN AST ALT TB TP A/G CEA
E G N
1/15 141 3.41 97.3

DIET: NPO E
BALANAY, ERNESTO BIGGAYAN CONTUSION 1/102020
HEMATOMA, LEFT MEDICATION:

68/M TEMPOROPARIETAL Ampicilin-Sulabctam
AREA 1.5g IV q8
DOB: 10/15/1951
Mannitol 150 cc IV q4 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOA: 01/14/20 with BP precaution 1/14/20 25.1 128 0.38 88.2 3.7 8.7 0.1 0.2 230 90 31 338
Ketorolac 30 mg/IV q8
CC: LOC PRN for pain
Kcl drip: 900cc PNSS +
NOI: FALL 10 meqs Kcl x 1 hr x 2
cycles CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
TOI: 7 PM ISTRY SE MIN LIN G
1/14 136.40 3.71
PLAN:
DOI: 1/06/20 /20
pls repeat chest CT scan
continue mannitol 150cc PT INR % Control PTT Control
q4hours
2nd Hospital stay repeat CBC, NA, K,
protime
TM-B INITIAL DX: IVF: PNSS 1L x 8h NITRAT

CONSEJERO, DOMINICK GONZALES PENETRATING INJURY 1/14/20
LIGHT
CLEAR 1.030 6.0 ++ - - - - - - - 0 1 1 3 3
YELLOW
10TH INTERCOSTAL MEDICATION:
21/M SPACE MIDAXILLARY Cefoxitin 1g/IV q12
LINE, LEFT Metronidazole 500mg/
DOB: 06/17/1998
IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOA: 01/14/20 Omeprazole 40mg/IV 1/14/20 16.5 146 0.43 89.7 4.8 5.1 0.2 0.2 180 82 28 338
OD
CC: STAB WOUND Ketorolac 30 mg/IV q8
Vit. K amp IV q8
NOI: STAB WOUND
PLAN:
TOI: 12:30AM Start incentive CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
spirometry
1/14 137.80 3.37
DOI: 1/14/20 daily wound care /20
continue meds
POI: CAMALANIUGAN
2ND HOSPITAL STAY
1/08/2020 14.80 26.20
AISLES RIGHT
AR INITIAL DX: IVF: PNSS 1L x 8h NITRAT
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
DOA: 01/16/20 OD
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
ISTRY SE MIN LIN G
For cervical XRAY APL
TOI: 12:30PM
DOI: 1/16/20
POI: PENABLANCA PT INR % Control PTT Control
CRITICAL CARE ROOM

NITRAT
CCR INITIAL DX: DIET: Soft Diet then add 1/10/2020
2 egg whites each meal

MULTIPLE STAB
WOUND 8TH ANCILLARY:
ARNEDO, SEVERINO GALARCE INTERCOSTALS CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
SPACE, RIGHT. LEFT MEDICATION: 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. Human Albumin, 1 Vial
POSTERIOR ARM, to run for 6hours q12
LEFT
MONITOR VS q2 and
record 1/09/20 3.63 142.61 98.64
DOB:07/26/1967 Monitor input and 1/12/2020 4.11
output qshift
1/14/2020 21 26.30 47 0.8
DOA: 0
CC: Stab wound Continue incentive
spirometry
Luis Encourage ambulaltion
Continue present
management
NITRAT
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
6th hospital day BACK, POST AXILLARY

LINE; POINT OF PLAN: 1/12/2020 11.40 19.70
Varma
ENTRY 4; LEFT For Removal of Foreign
MEDIAL FOREARM; body
POINT OF EXIT 4;
NONE
NITRAT
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
MAXILLARY LINE PLAN:
Continue incentive
spirometry
DOB:11/ 14/ 1994 Daily CTT care CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
DOA: 12/ 26/ 2019 1/06 133.10 4.57

/20
1/12/ 61.6 137 4.26
CC: stab wound 20 0
23rd hospital stay PT INR % Control PTT Control
1/12/20 12.40 31.60

bincey
IVF: PNSS 1L X 8 HRS NITRAT

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 Omeprazole 40 mg IV
DOA: 01/15/2020
TEMPORAL OD
CC: LOC TRAUMATIC Ketorolac 30mg IV PRN
SUBARACHNOID for pain q6 CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
NOI: VA HEMORRHAGE ISTRY SE MIN LIN G
PLAN: 1/15 138.40 4.01

/20
TOI: 12 AM
Continue present
DOI: 1/15/20 Mangement PT INR % Control PTT Control
POI: BAGGAO 1/15/20 13.40 1.07 87.9 21.4
IST 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
LEFT LEG 1.5g q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
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
DOA: 01/14/20 PRN for pain

Omeprazole 40mg IV q24
CC: GROSS DEFORMITY ON LEFT Cefoxitin 1g IV q8
LEG Gentamycin 240mg IV x
7 days CHEMISTRY CREA BUN AMY LIPA NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
NOI: VA SE
PLAN: 1/15/20 140.40 3.43
TOI: 8:30PM GS/NSS cleared

may proceed with “E”
DOI: 1/14/20 debridement PT INR % Control PTT Control
Inform ortho service
POI: TUG. CITY 1/15/2020 14.80 1.18 74.10 25.20
nd
2 HOSPITAL DAY
TRAUMA FEMALE A
PATIENT DIAGNOSIS MEDICATIONS DIAGNOSTICS
NITRAT
IVF: PNSS 1L x12hours E
TFA INITIAL DX: DIET: DAT with SAP 1/102020

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 CHEM CREA BUN AMY LIPA NA K URE FAST CHOL TRIGLY HDL LDL ALT TB TP A/ CEA
DOA: 01/06/20 3. Salbu + iprat ISTRY SE A GLU E G
neb q6 1/06 138 4.18 5.00
/20
1/09 5.4 3.87 0.82 1.49 2.01
MONITOR VS q4 and /20
CC: VEHICULAR ACCIDENT record 1/10 137.20 4.08
/20
Monitor input and PT % INR CONTROL APTT CONTROL
9th
output q shift
HOSPITAL DAY
PLAN:
Bev
Repeat CXR Tomorrow
NITRAT
IVF: PNSS 1L x KVO E
TF-A INITIAL DX: DIET: DAT with SAP

INJURY SECONDARY CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
CORTEZ, JOHANN MICHAEL TO VEHICULAR MEDICATION: 1/09/20 13.0 162 0.45 81.6 12.3 5.9 0.1 0.1 213 82 30 359
ACCIDENT, ACUTE 1. Vitamin B
38/M
SUBDURAL Complex tab
HEMATOMA, LEFT 1 tab OD
FRONTOTEMPOROPA 2. Ampicillin-
DOB:05/01/64 RIETAL AREA 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
DOA: 01/09/20 3. Omeprazole 1/09/20 138.90 3.80
40mg IV OD 1/14/20 129.90 3.89

4. Mannitol PT % INR CONTROL APTT CONTROL
100cc 10pNSS
CC: VA q6 with BP
prec
HISTORY: Start Ascorbic

Acid500/mg tab
NOI: VA (MOTORCYCLE)
Start Mannitol 100cc/IV
TOI: 12AM Start Incentive
spirometry
POI: BAGGAO, CAGAYAN
PLAN:
DOI: 11/09/20 Continue Medications
WOF DOB, desaturation
9th HOSPITAL DAY
luis
NITRAT
IVF: D5LR 1LX 12HOUR E
TF-A INITIAL DX: DIET: May have general
liquids
EVICERATED BOWEL ANCILLARY:
SECONDARY TO CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
BARRERO, JAYCEE ANUA STABWOUND LEFT MEDICATION:
LOWER QUADRANT
26/M
Continue present
management
DOB: Jun 13 1993 Daily wound care CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
Encourage ambulation
DOA: 01/12/20
CC: Stab wound
HISTORY:
NOI: Stab wound
TOI: 7AM
POI: MACUNACON, ISABELA
DOI: 1/12/2020
4th HOSPITAL DAY
NITRAT
IVF: PNSS 1 L X 12 HRS E
TF-A INITIAL DX: DIET: LOW SALT, LOW
FAT DIET
CAPINLAC, ROMAN BASA CONTUSION
HEMATOMA, RIGHT CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
58/M ANCILLARY:
FRONTOTEMPORAL
DOB: 11/20/1963 AREA SEC. TO FALL
MEDICATION
Ampicillin- Sulbactam
DOA: 01/15/2020
1.5 g IV q8
Mannitol 150 cc q4
CC: LOC
Ketorolac 30 mg q8 IV CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
NOI: FALL PRN for pain

TOI: 5PM PLAN:
Decrease Mannitol to PT % INR CONTROL APTT CONTROL
DOI: 1/12/20 100cc q4 with BP
precaution
POI: ISABELA
2nd HOSPITAL DAY
TRAUMA FEMALE B
IVF: PNSS 1L KVO 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 DY Hazy 1.010 7.5 - TRACE + - - - - 24 5 1 1

-
PNEUMOHEMOTHOR ANCILLARY:
AX SECONDARY TO
LIZARDO, EDUARDO JR. UBERITA STABWOUND MEDICATION: 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 1. Celecoxib 1/9/2020 16.2 131 0.40 70 13.7 13.3 2.6 0.4 256 88 29 328
22/M
INTERCOSTAL SPACE 200mg/cap, 1 1/15/20 17.6 132 0.39 65.4 19.2 7.2 7.5 0.7 474 86 29 336
MIDCLAVICULAR LINE cap BID PRN

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

CC: STAB WOUND
PLAN:
DAT
HISTORY: For repeat CXR
NOI: STAB WOUND
TOI: 11PM
POI: LASAM, CAGAYAN
DOI: 11/07/20
9th HOSPITAL DAY
POST OP DAY 9
bincey
IVF: PNSS 1Lx 8 hrs

TF-B INITIAL DX: DIET: NPO UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
E
JARA, JUDY JR SEATRIZ T/C BRAIN ABSCESS,

ANCILLARY:
RIGHT
34/M
FRONTOTEMPORAL CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
MEDICATION
DOB: 04/29/1985 Ceftriaxone 2g IV q12
1/14/20 9.7 159 0.46 71.9 19.6 7.2 1.1 0.2 322 85 30 348
S/P E' CRANIECTOMY,
DOA: 01/14/20 RIGHT EVACUATION Vancomycin 1g IV q12
OF HEMATOMA FOR Ketorolac 30mg IV q8
CC: GENERALIZD BODY WEAKNESS ACUTE EPIDURAL PRN for pain
HEMATOMA,
TEMPORO-PARIETAL, PLAN: CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
(+) HEADACHE
RIGHT WITH Inset IFC and NGT
1/15/20 75.20 136.8 4.08 93
(+) DIZZINESS DEPRESSED SKULL Maintain 02 support .6
FRACTURE , RIGHT Facilitate CT scan with
(+) N/V FRONTOTEMPOROPA contrast PT % INR CONTROL APTT CONTROL
RIETAL SEC. TO VA facilitate creatinine 1/14/20 14.80 1.17 75.80 25.80
ESR: 24mm/hr
2nd Hospital stay
IVF: PNSS 1L X 8 HRS UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
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 1.5
HEMATOMA, RIGHT 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
TOI: 7PM PLAN: PT % INR CONTROL APTT CONTROL
Continue medication 1/14/20 12.70 97 1.02 25

DOI: 1/09/20 Daily wound care
WOF:
POI: AMULUNG Neurodeterioration
2nd hospital day
ISOLATION
GS1
IVF: D5LR 1L X 8 HRS UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
GS-1 INITIAL DX: DIET: NPO 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
4ND HOSPITAL DAY For CP eval prior to OR
For E appendectomy 1/14/20 136.80 3.82
Secure Materials for OR

Send OR request
1/14/20 12.90 94.20 1.03 31.50
NITRAT
LY Clear 1.025 - - - - - - - - - 0-1 0-2 +
PASCUA, RANNY JR ACIO S/P POST E ANCILLARY

DECOMPRESSIVE MEDICATION
18/M HEMICRANIECTOMY ampicillin-sulbactam CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
FOR ACUTE EPIDURAL 1.5g/IV 1/16 9.9 146 0.44 54 22 9.7 12.1 0.9 316 80 26 332
DOB: 02/16/2001
HEMATOMA LEFT omeprazole 40mg/IV
DOA: 01/16/2020 TEMPORAL ARA Vitamin K amp/IV
WITH ketorolac 30mg/IV
CC: S/P E DECOMPRESSIVE INTRAPARENCHYMAL paracetamol 1g/IV
HEMICRANIECTOMY COMPONENT CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
SECONDARY TO MONITOR: VS q4 and
1/16 63.20 140.30 4.29
1ST HOSPITAL DAY VEHICULAR record
ACCIDENT Monitor I&Oqshift and
record PT % INR CONTROL APTT CONTROL
1/16 15.80 28.90

PLAN:
For cranioplasty
tomorrow
send OR request
NITRAT
LY Clear 1.015 7 - - - - - - - + 0-2 1-3 +
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
1ST HOSPITAL DAY record
1/16 142.30 3.71
PLAN:
For medical PT % INR CONTROL APTT CONTROL
management
OVERFLOW
NITRAT
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:
Refer to IM-ENDO
CC: NECK MASS
for comanagement PT % INR CONTROL APTT CONTROL
once result of
Hba1c and UA is
HISTORY: available
3rd hospital day
luis
NITRAT
IVF: PLRS1L x KVO E
ROOM: OF INITIAL DX: DIET: DAT with SAP 1/13/2020 LY Clear 1.020 6 - - - - - - - +++ 9 57 12 521
INVASIVE DUCTAL ANCILLARY:

CARCINOMA RIGHT
GONONG, REDENTA ROMERO T3N2Mx? Of III A MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Ketorolac 30mg IV q6 x
55/F 1/13/20 7.9 137 0.42 55.4 33.2 7.4 3.2 0.8 280 81 27 329
6 doses
Celecoxib 200mg/tab
BID x 3 days
DOB: July 23 1964 Tramadol 50mg/ IV q6 x
4 doses
CHEMISTRY CREA BUN AMY LIPAS NA K CL FAS CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
DOA: 1/13/2020 Ondansetron 4g/IV E GLU
1/13/2020 136.5 4.49
MONITOR VS q4 and
record
CC: HX of CA Monitor input and
output qshift
HISTORY: PLAN:
1/13/20 12.20 27
Start ascorbic acid

3rd hospital day Start B complex
Encourage ambulation
varma Daily wound care
URO
NITRAT
IVF: D5LR X 8 HRS E
URO INITIAL DX: DIET: NPO 1/16/2020
Light
Cloudy 1.010 9 - - ++ - - - - - 0-1 2-4 - +++
yello
CASTILLO, EDIMAR CARMELO INDIRECT INGUINAL ANCILLARY:

HERNIA, LEFT MEDICATION
34/M INCARCERATED Ampicillin-Sulbactam 1.5
g IV q8
DOB: 04/17/85 1/16/2020 11 136 0.40 90 5.9 2.8 0.3 0.3 266
Ketorolac 30mg IV PRN

DOA: 01/16/2020
for pain
CC: SCROTAL MASS Omeprazole 40mg IV OD
E GLU
PLAN: 1/16/2020 135 4.53
Insert NGT, IFC
for E mesh hemioplasty
WOF severe abdominal
pain, vomitting
GS3
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
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
14th hospital stay PLAN:

Continue present Meds
jesserene
Carry out pedia notes

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
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

6th hospital stay record
Monitor input and
output qshift
novi
PLAN:
Continue Medications
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
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
S/P EGD
May resume feeding
8th hospital stay
DISCHARGES
IVF: UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
GS-3 INITIAL DX: E
DIET: SOFT DIET Light
1/10/20 clear 1.015 6.5 - - + - - - - - 3 2 1 0 2
yellow
LORENZO, JANIMFA ABELLA ACUTE APPENDICITIS ANCILLARY:
11/F MEDICATION
Cefoxitin 785mg IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 12/26/2008
1/10/20 17.4 129 0.38 91.3 4.9 3.6 0 0.2 513 79 27 340
Metronidazole 275 mg IV
DOA: 01/10/2020
q8
CC: RLQ PAIN
Omeprazole 20 mg IV
OD
CHEMISTRY CREA BUN AMY LIPASE NA K CHOLE TRIGLY HDL LDL GLOBULIN AST ALT TB TP A/G CEA
1/12/20 91.20 138.8 3.36
NITRAT
IVF: D5LR X 8 HRS E
OF INITIAL DX: DIET: NPO 1/13/2020
Light
clear 1,015 7.5 - - - - - +++ - - 15 6 1 3 14
yello
DANGA, JUAN ASUNCION INDIRECT INGUINAL ANCILLARY:

HERNIA, LEFT MEDICATION
65/M INCARCERATED Ampicillin-Sulbactam 1.5
g IV q8
1/13/20 8.2 143 0.42 50.9 30.4 9.5 8.7 0.5 196 91 31 343
DOB: 02/2/1954 Ketorolac 30mg IV PRN
for pain
DOA: 01/13/2020 Omeprazole 40mg IV OD
CC: PLAN: E GLU
1/14/20 124 137.8 3.95
Continue present 0
medication
1/13/20 13.4 1.07 87.90 26.2
SPUTUM: ! AFB STAIN=0; 2 AFB STAIN= 0
NITRAT
IVF: PNSS 1L x E
TM-B INITIAL DX: 25gtts/min 1/102020
DIET: Dat with SAP

MULTIPL PHYSICAL
TOLDA, MARK JUDE DUYAO TO VEHICULAR CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT, ACUTE MEDICATION: 1/08/20 22.8 108 0.32 95.2 2.9 1.8 0.0 0.1 344 79 26 335
6/M
EPIDURAL 5. Ceftriaxone ig
HEMATOMA, RIGHT TIV q12
PARIETAL, 6. Ranitidine
DOB: 12/08/13 SECONDARY TO 25mg TIV q8
VEHICULAR 7. Paracetamol CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
DOA: 01/08/20 ACCIDENT, 250mg TIV q6 ISTRY SE MIN LIN G
PNEUMOCEPHALUS PRN for pain 1/08 135.30 4.48

/20
8. Mannitol 30cc
IV q8
CC: VEHICULAR ACCIDENT
PLAN: 1/08/2020 14.80 26.20
repeat cranial CT scan

HISTORY:
NOI: VA
TOI: 11:30AM
POI: STA ANA, CAGAYAN
DOI: 01/08/20
7th
HOSPITAL DAY
Tamil
NITRAT
TM-B INITIAL DX: DIET: soft diet 1/03/20 yellow HAZYr 1.030 6.0 Neg trace + Normal Neg +++ Neg Neg 452 88 9 5 97

DELEON, GREGORIO CARDONA TO VEHICULAR 6. Cefoxitin CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; ACUTE 1g/IV q8
25/M 7. metronidazol
1/11/20 9.1 101 0.33 90.1 5.8 3.9 0 0.2 389 70 21 304
SUBDURAL 1/14/20 11.0 82 0.27 84.3 5.2 4.8 5.5 0.2 423 71 21 299
HEMATOMA LEFT e 500mg/IV
TEMPOROPARIETAL; 8. omeprazole
DOB: 04/12/1994 PNEUMOCEPHALUS; 40mg/IV
DEPRESSED SKULL 9. ketorolac
DOA: 01/10/2020 FRACTURE , LEFT 30mg/IV
PARIETAL 10. paracetamol 01/11/2020 133.50 3.37
1g/IV
1/12/2020 4.20
11. nalbuphine
CC: STAB WOUND 10mg/IVq4 1/14/2020 142.20 3.44
12. nirpid PT % INR CONTROL APTT CONTROL

1/2Lx24hours
HISTORY:
NOI: STAB WOUND PLAN:

Continue meds
TOI: 8:40PM
Daily wound care
POI: BAGGAO CAGAYAN For wound GSCS
Removal of skin stapler
DOI: 01/10/20
6th hospital day

Bev
NITRAT
IVF: PNSS 1L x55ugtts E
TM-A INITIAL DX: DIET: Diet for age include 1/102020
Light
Clear 1.015 6.0 Neg Neg + Neg Neg Trace Neg Trace 2 71 7 0 207
yellow
1 banana/meal
MULTIPLE PHYSICAL
OCHOA, JOHN CARLO TO VEHICULAR
ACCIDENT, ACUTE MEDICATION:
7/M 1/10/20 20.8 111 0.32 80.2 10.2 8 1.4 0.2 363 74 26 344
EPIDURAL 7. Ampicillin-
HEMATOMA, Sulbactam 750mg
FRONTAL AREA IV q8
DOB:12/22/12 ACUTE SUBDURAL 8. Cefipime 2g IV q8
HEMATOMA, 9. Paracetamol
DOA: 01/02/20 TEMPORAL AREA 300mg q6 for pain CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
PNEUMOCEPHALUS and RTC

1/10/20 135 3.73
LINEAR SKULL 10. Vit C 500mg IV q12
FRACTURE 11. Vit K 10mg IV q8 1/12/2020 139. 3.40
50
CC: VEHICULAR ACCIDENT 12. Human albumin 1 PT % INR CONTROL APTT CONTROL
vial x 2hrs q12
HISTORY: MONITOR VS q4 and

record
NOI:VA
PLAN:
TOI: 6PM Continue Medications
daily wound care
POI: BACUUD, IGUIG WOF:
neurodeterioration
DOI: 01/09/20 repeat cranial CT Scan
6th day
Jesserene
NITRAT
IVF: PNSS 1L x E
TM-A INITIAL DX: 40ugtts/min
DIET: Diet for Age
MULTIPLE PHYSICAL
BACUYAG, NYLMER CLYDE TO VEHICULAR
GUMARANG ACCIDENT; ACUTE MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
SUBDURAL 13. Ceftriaxone 1/11/20 12.5 104 0.32 68.4 22.6 5.1 3.5 0.4 404 78 25 325
3/M
HEMATOMA LEFT 485mg/IV
TEMPOROPARIETAL; 14. Paracetamol
PNEUMOCEPHALUS; 190mg/IV
DOB: 11/13/2016 DEPRESSED SKULL 15. Mannitol
FRACTURE , LEFT 25cc/IV CHEMI CRE BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
STRY A SE MIN LIN G
DOA: 01/11/2020 PARIETAL
MONITOR VS q4 and
record
01/11/ 137.80 3.69
CC: FALL 2020

daily wound care
HISTORY: daily hygiene 1/11/2020 12.90 34.60
WOF:
NOI: FALL
Neurodeterioration
Continue Meds
TOI: 5PM
POI: GONZAGA CAGAYAN
DOI: 01/10/2020
5th
Hospital stay
Luis

Trauma Male A: General Surgery: Team I Dr. Tamani/Lingan/Aguisanda/Baculi/Casco/ Bulusan

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Trauma Male A: General Surgery: Team I Dr. Tamani/Lingan/Aguisanda/Baculi/Casco/ Bulusan

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GENERAL SURGERY: TEAM I

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

JANUARY 16, 2020

DOI: 01/06/20 PLAN:

PT INR % Control PTT Control

POI: GONZAGA CAGAYAN

6th Hospital stay

MULTIPLE PHYSICAL ANCILLARY:

14th hospital day

MONITOR VS q4 and 1/11/20 133 4.39

PLAN: PT % INR CONTROL APTT CONTROL

5th Hospital day

POI: ENRILE CAGAYAN

1STh Hospital day

MULTIPLE PHYSICAL ANCILLARY:

POI: SOLANA CAGAYAN

1ST hospital day

MULTIPLE PHYSICAL ANCILLARY:

1ST HOSPITAL DAY

ACUTE EPIDURAL ANCILLARY:

Daily wound care

decrease manitol to 75cc

ACUTE EPIDURAL ANCILLARY:

POI: TUMAUINI, ISABELA

1ST HOSPITAL DAY

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

1/15/2020 15.30 1.22 70.2 26.7

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

PT INR % Control PTT Control

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

HEMATOMA, LEFT MEDICATION:

TM-B INITIAL DX: IVF: PNSS 1L x 8h NITRAT

POI: PENABLANCA PT INR % Control PTT Control

CRITICAL CARE ROOM

2 egg whites each meal

MULTIPLE GUNSHOT ANCILLARY:

6th hospital day BACK, POST AXILLARY

MULTIPLE STAB ANCILLARY:

DOA: 12/ 26/ 2019 1/06 133.10 4.57

1/12/20 12.40 31.60

IVF: PNSS 1L X 8 HRS NITRAT

PLAN: 1/15 138.40 4.01

POI: BAGGAO 1/15/20 13.40 1.07 87.9 21.4

IST HOSPITAL DAY

AGUILLON, CHRISTIAN DAVE MULTIPLE PHYSICAL ANCILLARY:

DOA: 01/14/20 PRN for pain

PLAN: 1/15/20 140.40 3.43

TOI: 8:30PM GS/NSS cleared

MULTIPLE PHYSICAL ANCILLARY:

MULTIPLE RIB 2. Celecoxib

MULTIPLE PHYSICAL ANCILLARY:

40mg IV OD 1/14/20 129.90 3.89

HISTORY: Start Ascorbic

PT % INR CONTROL APTT CONTROL

CC: Stab wound

NOI: Stab wound

POI: MACUNACON, ISABELA

4th HOSPITAL DAY

NOI: FALL PRN for pain

2nd HOSPITAL DAY

TF-B INITIAL DX: DIET: DAT DY Hazy 1.010 7.5 - TRACE + - - - - 24 5 1 1

MIDCLAVICULAR LINE cap BID PRN

1.5g IV q8 1/15/20 136.10 4.15