GS1 / TRAUMA

DR. CONSTANTINO/ DR. HEBRADO / DR. SAMONTE / DR. PAZZIUAGAN

OCTOBER 22, 2023 3:00am

STATUS: FROM TOTAL ADMISSIONS: 8 Trauma: 4 WARD: 23 EXPIRED: DISCHARGE: 3 HAMA:

PATIENTS: 23 TCVS: 2 ER:

Neuro:12 PACU: TOS: 3 THOC: 2

Others: 5 SICU:

AMETHYST:

JADE:

AMBER: 2

TMA

PARACAD, JAYPI M. 2 weeks PTA, onset of postprandial
vomiting, (+) hemoptysis, (+)
32/M/M dizziness upon sudden movement.
No consultation was done. No
Gamu, Isabela medications were taken.
DOA:09/22/2023 FHPTC, persistence of the above
s/sx, hence consultation
PNEUMOCEPHALUS PARIETAL AREA RIGHT CT scan: 09/30 DAT + Ensure
S/P craniotomy frontotemporal, bilateral (03/21/23) -Stable size of the sellar-
suprasellar mass, as described,
S/P evacuation of tension pneumocephalus consider malignancy IVF: PNSS 1L x 12h
(10/10/23)
-Stable size of the air-filled
S/P nasal bone reduction (10/14/23) cavity, right frontal lobe
Refer back to ENT for possible TOS
-Malacic change, bilateral frontal
lobes

-Midline shift to the left For repeat CBC,PT, PTT now

-Craniectomy defect, bilateral Follow up referral to Hema without fail

Hematolo 10/16/23 10/17/2 10/18/2 10/20/2 fronto-parietal bones
gy 1hr post 3 3 3 Continue present medications
pt 6hrs
Mannitol at 100cc/IV Q8
post bt
Hgb 87 110 100 CT scan: 10/06
Ascorbic Acid 500mg/tab
Hct 0.27 0.33 0.30 -Decrease in size of the air-filled
Vitamin K 1amp/IV q6
RBC 3.10 4.17 3.71 cavity in the right frontal region.
PLT 162 202 254 Tranexamic acid q8
-Encephalomalacic changes,
WBC 8.1 6.4 7.6 both frontal lobes s
Neutrophil 62.3 63.3 60.6
-Solid, heterogeneous mass in
1
Lymphocy 21.9 19.8 23.9 the sellar/suprasellar region
tes
likely from neoplastic processes.
Monocyte 10.2 8.2 9.4
Eosinophil 5.0 7.8 5.7 -Craniotomy defects, bilateral
frontal bones.
PT 20.70 15.20
PTT 36.70 28.00

Body fluid analysis 10/10/23

specimen CSF

amount approximately 10mL

color colorless

transparency clear

specific gravity 1.015

pH 7.5

WBC 38.1

RBC 29.0

Polymorphonuclear cells 72

mononuclear cells 28

Hematolo 09/22/2 10/06 10/10 10/12 10/16

gy 3 /23 /23 /23 /23

2
 Hgb 144 133 136 118 78

Hct 0.44 0.40 0.42 0.36 0.24

RBC 5.36 4.94 5.23 4.34 2.91

PLT 243 295 305 207 211

WBC 8.2 6.1 11.8 14.2 6.3

Neutrophil 74.2 52.7 78.4 81.4 63.9

Lymphocyt 19.7 32.3 14.3 12.4 22.7

es

Monocyte 4.4 7.4 3.8 4.6 7.4

Eosinophil 1.1 6.8 3.1 1.0 5.5

PT 13.5 14.30

PTT 30.60 36.10

Clinical 09/22/23 10/04/23 10/10/23

Chemistry

Na 141.30 139.70 139.90

K 3.7 3.99 3.77

Urea 3.8

Creatinine 88.9 94.00 75.40

3
 AST 22

ALT 13

Urinalysis 09/22/23

Color Yellow

Transparency Hazy

Ph 6.0

Sg 1.030

Protein Neg

Glucose Neg

Ketones ++

Blood Neg

Bilirubin Neg

Urobilinogen Normal

Nitrite Neg

Leukocyte Neg

WBC 0-17/Hpf

4
 RBC 0-11/Hpf

EC 4/Lpf

Hyaline Cast 6/Lpf

Bacteria 10/Hpf

Mucus Threads 1

ABG 09/22/23

pH 7.36

pCO2 48.2

pO2 40

HCO3 27.0

B.E. 0.8

O2 sat 72%

Fi02 21%

CRUZADO, SOFIA 12 days PTC, (+) of fever BRAIN ABSCESS LEFT TEMPOROPARIETAL AREA Cranial CT scan: (9/28/2023) Diet for age; NPO post lunch
associated with colds, vomiting, S/P BURRHOLE, ASPIRATION OF ABSCESS
1/F/S 2x of loose stools. Paracetamol Hypodense mass, left
gave temporary relief. There was frontotemporal lobes with coarse
Calayan, Cagayan no consultation done. calcifications, peripheral IVF: Heplock; shift to D5LRS x 41-42
enhancement and mass effect cc
8 days PTC, sudden onset of Hematology 09/30/23
flexion of the third and foutth Obstructive hydrocephalus with For “E” evacuation of brain abscess
DOA: 09/09/2023 trans-ependmal edema this PM
digit, right hand and leg
Hgb 133
5
 weakness with no fever. Left to right subfalcine herniation For repeat CBC, PT, PTT, Na, K, Cl,
Crea

For repeat CXR-PA

2 days PTC, pt sought consult Hct 0.42 Cranial CT Scan with Contrast
and was diagnosed as a case of (10/16/23) Continue present medications
CNS infection vs Hydrocephalus.
Patient was then referred to our Plt 162 Follow up study shows no
institution for further evaluation significant interval change in the
and management. previously noted large Meds:
WBC 8.9 intracranial hypodense mass
with coarse calcifications and - Oxacillin 470 mg/IV q6
peripheral enhancement in the
- Metronidazole 470 mg/IV q8
Neutro 44.8 left frontotemporal lobes.
- Ceftriaxone 110 mg/IV q12
Left to right midline shift is again
Lympho 43.7 seen.

Mono 10.0

Eo 1.4

Hb 133

Clinical 09/29/2023
Chemistry

Na 128.90

K 4.15

TELAN, JOSE NOI: VEHICULAR CRASH MPI SECONDARY TO VEHICULAR CRASH, Soft diet w/ SAP
TRAUMATIC SAH
TOI: 11;40 AM PNSS 1L x KVO

60/M/M DOI: 10/15/23 Continue Meds

POI: [PENABLANCA For repeat Plain Cranial CT Scan

PENABLANCA, Hematology 10/15 10/19 For refer to IM-Neuro re: Right sided
CAGAYAN Body weakness
HGB 132 108

6
DOA: 10/15/23 HCT 0.41 0.34 Repeat CBC, Na, K,

PLT 263 208 VS q2

Continue present medications

WBC 22.8 9.1

Neutro 9O.7 79.4

Meds:
Lympho 3.7 11.8
Amphi-SUlbactam 1.5g IV now then
Mono 5.4 6.5 q6

Eo 0.0 1.9 omeprazole 40mg IV now then OD

Ketorolac 30mg IV now then q8

tranexamic acid 1g/ IV now then

500mg/IV q8 x 4 doses

CHEMISTRY 10/15 10/19 Mannoitol 100CC IV q8

losartan 50mg / tab 1 tab OD

SODIUM 146 147.50
Nimodipine 30mg tab, 2tabs q4 PO x
POTASSIUM 3.58 3.21 21 days

CREA 93.40 55.80

TROP I 0.03

IONIZED 1.56
CALCIUM

CK-MB 13

MAGNESIUM 2.50

Glucose 6.10
fasting

cholesterol 4.55

TAG 0.81

HDL 0.81

LDL 3.08

VLDL 0.37

7
 SEROLOGY 10/19

TSH 0.7190

ABALOS, GINA 1 month PTA, patient had leg pain Soft Tissue Mass Left Posterior Thigh probably XRAY Left Knee AP/Lat: DAT
Left associated with swelling, no Malignant (10/14)
36/F other s/sx. No medications and no IVF: PNSS 1L x 12 hours
consultations done. Consider cellulitis of the distal
CABAGAN, ISABELA thigh. Daily wound care
On interim, there was persistence
Hematology 10/19 10/21 Mild osteoarthritic changes of the For Bone Scan Right
of the above symptoms with
enlarging left leg. The patient took left knee
DOA: 10/14/2023 HGB 103 105 Referred to Ortho
Ibuprofen and claimed temporary
relief. Still no consultation done. For repeat CBC
HCT 0.34 0.35
4 days PTA, the patient had XRAY Left Leg AP/Lat: (10/14)
Shift antibiotic to Clindamycin 600 mg
musculoskeletal UTZ but the PLT 314 341
Consider cellulitis of the distal IV then q6
patient still had pain and swelling of
WBC 14.7 12.2 thigh and leg
the left leg. No consultation done
Mild osteoarthritic changes of the
FHPTA, the patient came in to our Neutro 82.7 78.6 Medications:
left knee
institution for further evaluation.
Lympho 11.5 15.4 Ampicillin-Sulbactam completed
(10/21)
Mono 4.8 4.8 XRAY Pelvis AP: (10/14)

Eo 0.7 0.8 No localizing Pelvic sign

PT 13.20

% Act 95

INR 1.03

PTT 26.60

CHEMISTRY 10/19 10/21

SODIUM 139.70 143.20

POTASSIUM 3.11 3.37

CREA 45.20

TMB

8
CANAPI, Few hours prior to consult, patient ACUTE APPENDICITIS RIGHT LOWER QUADRANT IVF: D5LRS 1L/ x 96cc/hr
CHRISTOPHER noted with abdominal pain non- ULTRASOUND (10/19/23)
radiating characterized as For possible MGH
12/M squeezing pain with an intensity of Examination of the right lower
quadrant using compression Continue Medications
8/10 associated with vomiting. No
AMULUNG, CAGAYAN technique shows aperistaltic,
other associated signs and
tubular structure measuring 0.5
symptoms such as fever, colds, and Hematology 10/18/23
cm in widest AP diameter: No
diarrhea. Hence consult and abnormal fluid collection is Medications:
DOA: 10/18/2023 admission. hgb 131
noted.
Metronidazole 300mg/IV q8
hct 0.41 IMPRESSION:
Ceftriaxone 1g/IV OD
RBC 5.05 peristaltic, tubular structure in
the right lower quadrant of the Omeprazole 20mg/IV OD
Platelet ct 374 abdomen, likely the appendix.
Suggest clinical and laboratory
WBC 10.9 correlation.

Neutrophils 86.9

lymphocyte 8.5

monocyte 3.9

eosinophil 0.1

PT 14.70

PTT 30.50

IMMUNO-SERO 10/18/23

CRP 1.540

Clinical Chemistry 10/18/23

sodium 138.90

potassium 4.20

creatinine 43.00

9
CRISTAL, RHEINDEN NOI: Vehicular Crash MULTIPLE PHYSICAL INJURY SECONDARY TO Diet for Age
VEHICULAR CRASH, FRACTURE OPEN COMPLETE
3/M TOI: around 9:15 am DISPLACED TIBIA RIGHT, FRACTURE CLOSE D5NSS 65 cc/hr
COMPLETE DISPLACED FEMUR RIGHT
ALCALA, CAGAYAN POI: Piggatan, Alcala Paracetamol 130 mg/IV q6

DOI: 10/18/23 Ampicillin Sulbactam 350mg/IV q8

DOA: 10/18/23 Hematology 10/18/23 10/19/23 Omeprazole 10 mg/IV OD

Hgb 91 74
Tranexamic Acid 150 mg/IV q8 x
Hct 0.28 0.22 6doses
RBC 3.52 2.91
Refer back to ORTHO for TOS
WBC 18 10.1
Neuro/GS cleared
Platelet 436 279
Neutrophils 75.0 51.8
Lymphocytes 16.2 35.9
Pedia:
Monocytes 7.9 11.0
Change IVF to D5LRS 1L x 45 cc/hr
Eosinophils 0.6 1.0
PT 15.30 Transfuse 2nd aliquot of PRBC

% Activity 75.00 For repeat CBC 6 hours post BT

INR 1.22
PTT 29.20

Clinical 10/18/23
Chemistry
Na 139.10
K 4.14
Crea 33.00

PAMITTAN, OSCAR C. 3 weeks PTA, patient noted to INFECTED WOUND NAPE AREA Diet as tolerated
have a pustule on the nape area.
No other associated signs and Continue present medications
symptoms like fever, nausea,
60/M/M Refer to IM-Cardio regarding HTN
vomiting. No consultation done. No CHEMISTRY 10/16 10/17
medications taken.

10
ENRILE, CAGAYAN Interim, persistence of symptoms, Sodium 132.60 Atorvastatin 40mg Tab ODHS
now increasing in size, prompted
consult at a PMD where the patient Potassium 3.86 Losartan OD
was given Cloxacillin with
DOA: 10/16/23 Creatinine 85.40 Clindamycin 600mg IV q6
levocetirizine which provides
temporary relief few hours PTC, Humulin R 20 “U” 5Q pre dinner
due to persistence of above above HBA1C 13.40
symptoms patient sought consult at Ketorolac 30mg IV q8
our institution, hence admission Glucose 16.60
fasting

cholesterol 4.87

TAG 1.53

HDL 1.09

LDL 3.08

VLDL 0.70

HEMATOLOGY 10/16

Hgb 149

Hct 0.43

RBC 4.86

Platelet 209

WBC 9.5

Neutrophil 66.3

Lymphocytes 23.4

Monocyte 7.8

Eosinophil 0.7

11
 CLINICAL 10/16
MICROSCOPY

COLOR straw

TRANSPARENCY clear

pH 6.0

SG 1.020

GLUCOSE +++

GALINDO, EUNICE NOI: VA Acute Epidural Hemorrhage secondary to occipital DAT with SAP Repeat Na, K
right acute subdural hematoma temporoparietal left
16/F/S TOI: 3:30 am secondary to vehicular crash IVF: PNSS IL X 12 D/C Ketorolac and Mannitol

572818 POI: Quirino CONTINUE MED AND

MONITORING
AGLIPAY,QUIRINO DOI: 10/17/2023 AMPICILLIN SULBACTAM 1.5
Hematology 10/19 G/IV Q8
DOA: 10/18/2023
Hgb 106

Hct 0.32

RBC 3.67

WBC 12.6

Platelet 348

Neutrophils 81.5

Lymphocytes 10.4

Monocytes 7.9

Eosinophils 0.0

PT 16.10

% Activity 69

INR 1.29

PTT 33.70

12
 CHEMISTRY 10/19

Sodium 135

Potassium 4.88

Creatinine 24.50

AGREGADO, ULYSSIS 1 week PTA, patient noted with GENERALIZED PERITONITIS SECONDARY TO NPO L1:D5LRS 1L X 8 hrs
RLQ pain with pain scale of 3/10. RUPTURED VISCUS
67/M / M No consult done and no DAILY WOUND CARE L2: PNSS 1L x 10 hrs
medications were taken.
ROXAS, ISABELA INCENTIVE SPIROMETRY 10- Continue medications
1 day PTA, persistence of 15X PER HOUR
abdominal pain now with pain scale
DOA:10/19/23 of 10/10, associated with episode of Hematology 10/19 Medications:
vomiting. Prompted consult to
nearby hospital were Labs and Hgb 149 Paracetamol 1g IV x q8 x 6 doses
diagnostics were requested.
Abdominal X-ray reveals Hct 0.44 Ketorolac 30 mg IV q 6 x 6 doses
Pneumoperitoneum. Hence Tramadol 50 mg SIVP q6 x 8 doses
referred in our institution. RBC 4.90
Metronidazole 500 mg IV q8
WBC 14.2
Ceftriaxone 2 g IV OD
Platelet 173 Omeprazole 40 mg IV OD

Neutrophils 95.4

Lymphocytes 2.0

Monocytes 2.5

Eosinophils 0.0

PT 14.10

% Activity 85.00

INR 1.11

13
 PTT 25.60

Clinical 10/19
Chemistry

Na 141.00

K 3.87

Crea 84.60

BALAIS, JOSE NOI: FALL TRAUMATIC BRAIN INJURY SECONDARY TO FALL NPO CONTINUE Mannitol at 150 cc iv q4

23/M/S TOI: 9 AM IVF PNSS 1L X 10

SAN MANUEL POI: IGUIG CT SCAN: FOR REPEAT PLAIN

ISABELA CRANIAL CT SCAN
DOI: 10/17/2023 ● Acute subdural hemorrhage,right temporal
DOA: 10/17/2023 convexity and left fronto-temporal DAILY WOUND CARE
convexities
CONTINUE MEDS AND
● Traumatic contusion hematomas, both MONITORING
frontal and temporal lobes

● Minimal subarachnoid hemorrhage

AR

AC

SANTIAGO, EFREN NOI: FALL TRAUMATIC SUBARACHNOID HEMORRHAGE DAT W/ SAP

SECONDARY TO FALL
53/ M / M DOI: 10/19/23 PNSS 1L x 12 hrs

Amulung, Cagayan POI: FALL Repeat CBC, Na, K

TOI: 1:00 AM HEMATOLOGY 10/19

DOA:10/19/23 Hgb 133 Revise tramadol

14
 Hct 0.40 Mannitol 150cc/IV q6

RBC 4.43 Ampicillin Sulbactam 1.5g/ IV q8

Ketorolac 30mg/ IV q8
WBC 14.2

Platelet 269

Neutrophils 83.6

Lymphocytes 8.9

Monocytes 7.1

Eosinophils 0.1

PT 12.20

% Activity 107.00

INR 0.96

PTT 22.90

Clinical 10/19
Chemistry

Na 144.80

K 3.23

Crea 75.50

SANTIAGO, REYNALD NOI: VA BLUNT CHEST INJURY, PNEUMOTHORAX RIGHT DAT wth SAP
SECNDARY TO VEHICULAR ACCIDENT
33/M/M TOI: 7 PM IVF: Heplock

STA. ANA CAGAYAN POI: Amulung Cagayan Repeat CBC, Na, K

DOI: 10/17/23 Hematology 10/18/23

DOA: 10/18/23 Ampicillin Sulbactam 1.5g q8

Hgb 141
Tramadol drip

Ketorolac 30mg IV
Hct 0.41
15
 Celecoxib 200mg cap BID

NAC 600mg tab OD

RBC 4.56 Salbutamol nebule q8

WBC 12.8
Continue incentive spirometry.

Daily CTT care.

Platelet 266

Neutrophils 75.4

Lymphocytes 15.7

Monocytes 8.5

Eosinophils 0.2

PT 14.40

% Activity 82.00

INR 1.14

PTT 28.50

Clinical 10/18/23
Chemistry

Na 140.50

K 3.74

Crea 85.70

16
TOLENTINO, NOI VEHICULAR CRASH ACUTE SUBDURAL HEMATOMA Secure 2 units PRBC Ampicillin Sulbactam 1.5g q8
MINERVINO FRONTOTEMPOROPARIETAL OCCIPITAL RIGHT
TOI 3:50PM CONTUSION HEMATOMA, TEMPORAL RIGHT Ortho: Copious wound Omeprazole 40mg IV OD
FRACTURE 4TH TO 5TH METACARPAL LEFT, flushing
POI GONZAGA CAGAYAN FRACTURE CLOSE COMPLETE DISPLACED FEMUR Mannitol 200 cc IV
71/M/M LEFT SEC TO VC Foam traction
DOI 10/20/23 Paracetamol 600 mg IV
573133

Hematology 10/18/23

Hgb 99

Hct 0.30

RBC 3.89

WBC 15.7

Platelet 103

Neutrophils 85.5

Lymphocytes 8

Monocytes 6.4

Eosinophils 0.0

PT 17.80

% Activity 60

INR 1.43

17
 PTT 26.10

Clinical 10/21/23
Chemistry

Na 141.70

K 3.33

Crea 118.40

PELOVELLO, NOI VC ACUTE SUBDURAL HEMATOMA Continue meds and Mannitol 100 cc IV q8
FERDINAND FRONTOTEMPORAL RIGHT, TRAUMATIC SAH, monitoring
TOI 6:15 PM MAXILLARY FRACTURE RIGHT INEAR SKULL Ceftriaxone 2g IV od
FRACTURE FRONTAL LEFT, FRACTURE CLOSED
POI BAGGAO CAGAYAN COMPLETE CLAVICLE LEFT SEC TO VC Paracetamol 600mg q6
51/M/M

18
DOI 10/20/23

Hematology 10/20/23

Hgb 134

Hct 0.38

RBC 4.45

WBC 10.6

Platelet 201

Neutrophils 84.8

Lymphocytes 9.7

Monocytes 4.8

Eosinophils 0.4

PT 13.10

% Activity 97

INR 1.02

PTT 23.30

19
 Clinical 10/21/23
Chemistry

Na 142.40

K 4.12

Crea 81.70

CORREO, PEDRO 10 months PTA patient noted with a Liposarcoma, Left thigh DAT Omeprazole 10 mg IV OD
mass on the left thigh. No consult
was done. No medications taken. IVF: PNSS 1L x 10 hours Paracetamol 300 mg IV q6

65/M 9 months PTA, patient sought Secure 2 units PRBC Furosemide 20 mg IV after each unit of
consult to our institution. Advised Hematology 10/20/23 PRBC
for MRI which revealed soft tissue For repeat CBC 6 hours post
sarcoma. 2nd unit of PRBC
Enrile, Cagayan Hgb 89
3 months PTA, patient undergone Refer to ORTHO for further
biopsy on the left thigh which evaluation and management

DOA:10/20/23 revealed liposarcoma. Hct 0.25

FF-up referral to IM-ONCO
Patient was subsequently admitted and Cardio without fail
to our institution. RBC 3.27

WBC 9.8

Platelet 308

20
 Neutrophils 81.6

Lymphocytes 9.5

Monocytes 7.6

Eosinophils 1.2

PT 11.70

% Activity 116

INR 0.91

PTT 28.90

Clinical Chemistry 10/20/23

sodium 121.70

potassium 5.06

creatinine 103.20

Albumin 30.30

CK-MB 3.0

Trop I <0.01

AR

21
AL

JI MONROY RAQUINI, JOJO CC: Seizure NPO

25/M/S Patient is a known case of acute PNSS 1L x 8

subdural hematoma right, acute Hematology 10/14/23 10/19/23
Aparri Cagayan epidural hematoma occipital lobe. Diazepam 5mg IV PRN for seizure
1-day PTC, patient noted to have
fever of 39, no meds taken. Sought Hgb 87 123 Omeprazole 40mg IV OD
consultation at Aparri provincial
DOA: 10/14/23 Phenytoin 10 mg IV q 8
hospital and was admitted
overnight. FHPTC, patient had Hct 0.27 0.37 Mannitol 100cc IV q 6 with BP precaution
seizure episode was referred to our
institution for further evaluation and
management. RBC 2.97 4.31
MGH GS wise.

WBC 35.5 9.8 Referred to IM-Neuro.

Platelet 617 412

Neutrophils 93.2 71.5

Lymphocytes 1.8 13.9

Monocytes 4.9 10.0

Eosinophils 0.0 .2

Clinical 10/14/23 10/19/23

Chemistry

Na 140.80 140.70

K 3.79 3.78

Crea 67.40 30.30

CCR
22
PIPO, VILLAMOR NOI: Vehicular crash MULTIPLE PHYSICAL INJURY SECONDARY TO Soft non chew diet
VEHICULAR CRASH, MANDIBULAR FRACTURE
26/M/S TOI: 6:30 AM LEFT, FRACTURE 4th DIGIT HAND LEFT IVF: PNSS 1L x 12

Lallo, Cagayan POI: Amulung Cagayan Ampicillin Sulbactam 1.5g q8

DOI: 10/19/23 Ketorolac 30mg IV q 8 for pain

Hematology 10/19/23
DOA: 10/19/23

Still for referral to Plastics.

Hgb 143
For Facial CT scan with 3D recon.

Hct 0.43 For Panoramic Xray - done.

RBC 5.05

WBC 18.6

Platelet 259

Neutrophils 88.2

Lymphocytes 3.5

Monocytes 7.9

Eosinophils 0.1

PT 12.60

% Activity 103.00

INR 0.98

PTT 25.90

23
 DUMAUA, CHARLIE NOI: Vehicular crash MULTIPLE PHYSICAL INJURIES SECONDARY TO DAT with SAP
VEHICULAR CRASH, MULTIPLE RIB FRACTURE,
60/M TOI: 8:15PM 2nd, 4th to 7th RIB LEFT, CLAVICULAR FRACTURE PNSS 1L KVO
LEFT
Sto. Nino Cagayan POI: Sto. Nino Cagayan Ketorolac 30mg IV q 8 RTC

DOI: 10/15/23 Tramadol 50mg IV q8 PRN

DOA: 10/16/23 Ampicillin-Sulbactam 1.5g IV q 8

Hematology 10/16/23 Salbutamol neb q 8

NAC 600mg/tab ODHS

HB 138

Continue chest physiotherapy.

HCT 0.42
Continue incentive spirometry.

PLT 267 Daily CTT care

WBC 12.7
Referred to Anes re: Pain Management

Neutro 78.2

Lympho 12.3

Mono 8.8

Eo 0.2

TFA

PADDAYUMAN, ALVIN 2 days PTA, patient complained of
RLQ pain associated with dysuria.
Patient sought consult in a private
institution where he was managed
10/M as a case of UTI. He was then
discharged. He was then
ACUTE APPENDICITIS
Clinical Microscopy
UTZ of Whole Abd: NPO
Normal Sonogram of the Liver,
Gallbladder, biliary tree, IVF: D5LRS 1 L x 65 cc/hr
pancreas, spleen, aorta,
kidneys, and urinary bladder. Continue medications
10/21/23
24
 discharged with Cefalexin as take color yellow For “E” appendectomy
home meds.
Sta. Maria, Isabela transparency clear Refer to Pedia for Risk Stratification
1 day PTA, patient still complains of
RLQ pain which prompted a repeat pH 6.0
consultation at the same private
DOA: 10/21/23 institution. UTZ was done revealing Medications:
specific gravity 1.030 Omeprazole 20 mg IV OD
Normal Sonogram of the Liver,
Gallbladder, biliary tree, pancreas, protein + Ceftriaxone 850 mg IV q12
spleen, aorta, kidneys, and urinary
bladder. glucose neg Metronidazole 375 mg IV q8
Persistence of the above sx
prompted at our institution. ketones ++

blood neg

bilirubin neg

urobilinogen normal

nitrite neg

leukocyte neg

WBC 2/hpf

RBC 2/hpf

Epithelial cells 1/lpf

Hyaline cast 0/lpf

Bacteria 2/hpf

Mucus thread 0

SEROLOGY 10/21/23

CRP >10.00

Hematology 10/21/23

25
 Hgb 127

Hct 0.40

RBC 5.47

WBC 34.7

Platelet 719

Neutrophils 86.2

Lymphocyte 5.5

Monocyte 8.0

Eosinophil 0.1

PT 13.40

% activity 93

INR 1.05

PTT 25.70

Clinical Chemistry 10/21/23

sodium 132.80

potassium 4.88

creatinine 44.70

JACINTO, EROL CC: Hacking Injury Lacerated wound, Posterior Neck secondary to DAT Tranexamic acid 500 mg IVq8
hacking injury
IVF: PNSS 1L x 8 hours Ampicillin-Sulbactam 1.5 g IV q6

51/M NOI: Hacking injury Daily wound care Ketorolac 30 mg IV q6

POI: Lal-lo, Cagayan Hematology 10/22/23 Continue meds and monitoring Omeprazole 40 mg IV OD

Lal-lo, Cagayan DOI: 10/21/23 Hgb 104 FF-up CBC post BT result

26
 TOI: 9 pm Hct 0.32

DOA: 10/21/23 RBC 3.45

WBC 18.6

Platelet 240

Neutrophils 82.5

Lymphocyte 9.0

Monocyte 7.1

Eosinophil 1.2

PT 15.10

% activity 77

INR 1.20

PTT 27

Clinical Chemistry 10/22/23

sodium 142.50

potassium 3.91

creatinine 80.10

MATA, ROMEL NOI: VA Cerebral Concussion Avulsed wound Left Ear XRAY of Bony Pelvin – AP Soft diet with SAP
Secondary to VA VIEW (10/20/23)
TOI: 8:20 nn negative for fracture and/or IVF: PNSS 1L x 8 hours

27
20/M DOI: 10/20/23 dislocation Start Celecoxib 200 mg cap BID

POI: Burgos, Isabela Eperisone 50 mg IV TID

Burgos, Isabela XRAY of Lumbosacral spine Continue meds and management

Clinical Chemistry 10/20/23 – AP VIEW (10/20/23)
lumbosacral instability Daily wound care
sodium 140.40
DOA: 10/20/23
potassium 4.52

creatinine 67.70

Hematology 10/20/23

Hgb 101

Hct 0.32

RBC 3.44

WBC 21.1

Platelet 163

Neutrophils 85

Lymphocyte 6.8

Monocyte 7.5

Eosinophil 0.4

PT 15.30

% activity 75

INR 1.22

PTT 28.50

28
TFB

BURN

DUYAO, JESUS NOI: fall (kulong-kulong) CONTUSION HEMATOMA FRONTOTEMPORAL DAT

AREA, ACUTE SUBDURAL HEMATOMA,
37/M/M TOI: 10pm TEMPOPARIETAL AREA, RIGHT SECONDARY TO IVF: PNSS 1L x 12hours
FALL
Gattaran, Cagayan POI: Gattaran, Cagayan

DOI: 10/18/23 Ampicillin-sulbactam 1.5g/IV q8 (-)ANST

DOA: 10/19:2023 Ketorolac 30mg/IV q8 for pain

Hematology 10/19/23 Mannitol 100cc/IV q8

Hgb 148

Hct 0.45

RBC 5.13

WBC 14.8

Platelet 360

Neutrophils 82.3

Lymphocyte 10.0

Monocyte 7.4

Eosinophil 0.0

PT

% activity

INR

PTT

29
Clinical Chemistry 10/19/23

sodium 142.30

potassium 4.20

creatinine 63.00

Clinical Microscopy 10/19/23

color yellow

transparency clear

pH 6.0

specific gravity 1.030

protein neg

glucose neg

ketones neg

blood neg

bilirubin neg

urobilinogen normal

nitrite neg

leukocyte neg

WBC 3/hpf

RBC 0/hpf

Epithelial cells 2/lpf

Hyaline cast 0/lpf

Bacteria 0/hpf

30
 Mucus thread 0

Clinical Chemistry 10/20/23

sodium 141.40

potassium 3.61

creatinine 57.40

DALIT, CHRISTEL NOI VC CONTUSION HEMATOMA FRONTAL LEFT AND ENT: Aural toilette done Mannitol 200 cc IV Q6
FAYE TEMPORAL RIGHT ACUTE EPIDURAL HEMATOMA Medicated aural pack done
TOI 4:00 PM TEMPORAL RIGHT LINEAR SKULL FRACTURE Omeprazole 40 mg iv od
17/F/S OCCIPITAL RIGHT PNEUMOCEPHALUS SEC TO VC
DOI: 10/20/23 Ceftriaxone 2g IV od
573125
POI LUNA ISABELA Paracetamol 600mg q6

Hematology 10/20/23

Hgb 113

Hct 0.35

RBC 4.84

WBC 22.8

Platelet 355

Neutrophils 92.3

Lymphocyte 3.6

31
 Monocyte 4.0

Eosinophil 0.0

PT 15.60

% activity 73

INR 1.24

PTT 29.10

TMB

32