VALENZUELA MEDICAL CENTER FM-HIMD-007

Padrigal St., Karuhatan, Valenzuela City

Telephone No. 294-6711 Rev 2 – 04/01/16

SURNAME AGE HOSPITAL CODE:0000585

MANRIQUE 75 HOSPITAL NO. 9174127

GIVEN NAME SEX WARD / ROOM

CLEMENTE M

CLINICAL ABSTRACT

GENERAL DATA:

THIS IS THE CASE OF CLEMENTE MANRIQUE, 75/M, FROM MARILAO, BULACAN, WHO CAME IN AT OUR
INSTITUTION ON 05/14/21 AT 01:41PM WITH THE CHIEF COMPLAINT OF EPIGASTRIC PAIN.

COURSE IN THE WARD:

PATIENT UNDERWENT PRELIMINARY DIAGNOSTIC TESTS TO INCLUDE CBC PC, CHEST XRAY, CREA, NA, K, CL,
iCa, iMg, ALT, AST, 12L ECG, FBS, LIPID PROFILE, APPT/PT, URIC ACID, OPS/NPS, CBG MONITORING AND WHOLE
ABDOMINAL ULTRASOUND, OPS/NPS, HBA1C. HE RECEIVED MEDICATIONS TO INCLUDE OMEPRAZOLE,
TRANEXAMIC ACID, INSULIN. DAY 1. PATIENT WAS TRANSFUSED WITH 2 UNITS PRBS WHICH HE TOLERATED
WELL. HE RECEIVED CONTINUATION OF PREVIOUS MEDICAL MANAGEMENT. NGT WAS ALSO INSERTED AND
FOBT WAS FACILITATED. DAY 2. PATIENT WAS STARTED ON CLEAR LIQUIDS AND PENDING LABS WERE
FACILITATED. HE RECEIVED CONTINUATION OF PREVIOUS MEDICAL MANAGEMENT. DAY 3. PATIENT WAS
ALREADY SHIFTED TO GENERAL LIQUIDS. THE OMEPRAZOLE DRIP WAS SHIFTED TO PO MEDS. HE RECEIVED
CONTINUATION OF PREVIOUS MEDICAL MANAGEMENT. NO NEW SUBJECTIVE SYMPTOMS WERE NOTED.
DAY 4. PATIENT WAS STARTED ON SOFT DIET, HE RECEIVED 2 MORE UNITS OF PRBC WHICH HE TOLERATED
WELL. PENDING LABS WERE FACILITATED. HE RECEIVED CONTINUATION OF PREVIOUS MEDICAL
MANAGEMENT.
DAY 5. PATIENT WAS STARTED ON REGULAR DIET AND REPEAT CBC REVEALED CORRECTION OF ANEMIA. HE
WAS ADVISED THAT HE MAY GO HOME TOMORROW.
DAY 6 PATIENT PRESENTED WITH STABLE VITAL SINGS WITHOUT NO NEW SUBJECTIVE SYMPTOMS. HE MAY
GO HOME TODAY WITH PRESCRIPTIONS AND ADVISED FOLLOW UP AS OPD.

IMPORTANT LABORATORY EXAMINATION FINDINGS:

OPS/NPS: VIRAL RNA NOT DETECTED

CONDITION UPON DISCHARGED:

IMPROVED

FINAL DIAGNOSIS:

SEVERE ANEMIA SECONDARY TO UPPER GI BLEEDING SECONDARY TO BLEEDING PEPTIC ULCER DISEASE SEC
TO H.PYLORI SEC TO NSAID INTAKE; RESOLVING COVID ; HYPERGLYCEMIA INDUCED BY STRESS VS TYPE 2 DM

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