BUTUAN DOCTORS’ HOSPITAL

J.C Aquino Ave., 8600 Butuan City, Tel. NO. (085)342-7000

CLINICAL SUMMARY/MEDICAL ABSTRACT

NAME: Analcita D. Doce AGE: _ 58____ SEX: __F____

ADDRESS: ___Bonbon, Butuan City_____________________ DATE: August 22, 2020

ORDER OF RECORDINGS:

1. BRIEF HISTORY
3 days PTA, patient had sudden onset of fever and productive cough associated with
mild difficulty of breathing

2. PERTINENT PHYSICAL FINDINGS

Crackles on both lung fields
Tachycardia
Right middle lobe consolidation

3. IMPRESSION
Community-Acquired Pneumonia

4. MEDICATION
(Mahal ipahatod ra nako krn buntag ka wawa ang tambal mahal ha). Thank you
mahal

5. PROCEDURES

6. FINAL DIAGNOSIS
Community-Acquired Pneumonia, Moderate Risk

7. RECOMMENDATION
Continue meds

_____________________________
Physician Signature over Printed Name
Lic. No. __________________________
PTR No. _________________________
BUTUAN DOCTORS’ HOSPITAL
J.C Aquino Ave., 8600 Butuan City, Tel. NO. (085)342-7000