Patient Data

Name: Libuna, Arlene

Age: 55 years old
Gender: Female
Birthdate: June 22, 1968
Address: Purok Belo, San Felipe, South Cotabato, 9510
Nationality: Filipino
Occupation: Private Employee
Religion: Catholic

Date Admitted: March 23, 2023, 09:12 AM

Chief Complaint: Vehicular Accident
Diagnosis:
 Open Fracture, Proximal Third Tibia, Fibula, Left
 Lacerated Wound, Right Cheek
 Lacerated Wound, Posterior Right Leg
Attending Physician: Dr. Pascua
Case No.: 23-00682
Room/Bed No.: 336
Past Medical History:
 Hypertension
 G4P3A1
 1993 - Cesarean Section
 2018 - Appendectomy
Family Medical History:
 Hypertension
 Diabetes Mellitus
 Arthritis
Height: 162.5 cm
Weight: 62.5 kg
Vital Signs: BP: 150/90; CR: 77; RR: 22; T: 36.5; SPO2: 98; Pain Scale: 10/10
RBS: 120 mg/dL
GCS: 15/15
Blood Count: RBC: 4.71; WBC: 11.29; Platelet: 171.00
Urinalysis: Color: yellow; Clarity: cloudy; SG: 1.0015; PH: 7
X-RAY:
 Complete oblique displacement fractures distal 3 rd of left tibia and fibula
 No definitive evidence of fracture of the skull and elbow