BICOL MEDICAL CENTER
Concepcion Pequena, Naga City 4400
Tel. no.: (054) 472-61-25 to 31 | Email: bmc.nagacity@gmail.com
1197342
IMPORTANT REMINDERS ALAGANG PINOY TAGUBILIN
THIS FORM SHOULD BE FILLED UP-LEGIBLY
DISCHARGE SUMMARY
Health Record Number 1193742 Age/Edad: 22 yr(s). old
Name of Patient/Pangalan Sex/Kasarian: Female Chief Complaint / Reason for Admission:
PAYTE DANE NICOLE TOCINO DENGUE / EPISTAXIS
Last Name First Name Middle Name
Date Admitted: 05/31/2023 Time Admitted: 3:00 pm
Month Day Year hh: mm : am/pm
Date Discharged: Time Discharged:
Month Day Year hh: mm : am/pm
Brief History of Present Illness / History:
14 DAYS, THE PATIENT EXPERIENCED NOSE BLEEDING,VOMITING, HIGH FEVER AND HEADACHE.
2 DAYS PRIOR TO ADMISSION, THE PATIENT STILL EXPERIENCE VOMITING AND STILL HAS HIGH FEVER.
FEW HOURS BEFORE ADMISSION, THE PATIENT HAD HEAVY EPISTAXIS.
Physical Examination( Pertinent Findings per System)
General survey : Unconscious
Vital Signs : BP: 120/80 CR: 80 RR: 21 Temperature: 38.9
HEENT : Essentially normal GU: High
Chest/Lungs : Low Neuro Exam: ----
CSV : High
Course in the Wards (attached additional sheets if necessary)
05-31-2023 THE PATIENT WAS ADMITTED AND CONSENT WAS SECURED BY GUARDIAN. FOR COMPLETION OF ADMISSION, THE PATIENT IS
UNDER OBSERVANCE DUE TO UNCONSCIOUSNESS. IVF: D5LR 1L BY 20 GTTS/MIN WAS GIVEN. CBC WITH BLOOD TYPING,
URINALYSIS, HBSAG. RPR WAS REQUESTED. CEFOXITIN 1G WAS ADMINISTERED.
06-01-2023 THE PATIENT GAIN CONSCIOUSNESS, BUTORPHANOL WAS ADMINISTERED. TO RR NOW AND MAY TRANSFER TO WARD FOR
OBSERVANCE ONCE STABLE. TAKE ORAL MEDICATIONS AS FOLLOWS: ACETAMINOPHEN FOR PAIN, FESO4 1 TAB ONCE A DAY. TAKE
ANTIOXIDANTS AND VITAMIN C AS PER ADVISED BY DOCTOR
06-02-2023 THE PATIENT IS NOW FULLY AWAKE AND TAKEN TO WARD FOR FURTHER RECOVERY.
06-03-2023 REQUESTED FOR OTHER BLOOD TEST RESULT BECAUSE OF HIGH FEVER.
06-05-2023 THE PATIENT IS STABLE AND FULLY AWAKE AND TAKING ORAL MEDICATIONS ACETAMINOPHEN FOR PAIN, FESO4 1 TAB ONCE A
DAY. TAKE ANTIOXIDANTS AND VITAMIN C AS PER ADVISED BY DOCTOR.
06-07-2023 THE PATIENT MAY NOW GO HOME AND CONTINUE TAKING ORAL MEDICATIONS. FOLLOW UP AFTER 1 WEEK. JUNE 14,2023.
Pertinent Laboratory and Major Diagnostic Results
WHITE BLOOD CELL 10.02; RBC 1.056; HEMOGLOBIN 0.215; PLATELET COUNT 112
HBSAG: NON- REACTIVE
RPR: NON- REACTIVE
Disposition on Discharge
Improved Transferred HAMA Absconded Expired
BMC-F-MED-001 Rev. No. 3 Effectivity Date: February 10, 2016
PAYTE, DANE NICOLE TOCINO
Home Medications/ Gamot
TAKE ACETAMINOPHEN FOR PAIN
TAKE FESO4 1 TAB ONCE A DAY
TAKE ANTIOXIDANTS AND VITAMIN C AS PER ADVISED BY DOCTOR
Health Teachings/ Pangunahing Paalalang Pangkalusugan
WELL ADVISED
Other Instructions/ Karagdagng Paalala
FOLLOW UP ON JUNE 14, 2023 AT OPD.
Final Diagnosis / Sakit
(00023) DENGUE FEVER.
Operation/Procedure Done
59812 NO OPERATION/PROCEDURE DONE.
Other Procedures
CP / Endo Closed tube thoracostomy
Thoracentesis / Paracentesis Tracheostomy
Endotracheal Incubation Chemotherapy Procedure
Cut down, CPV Others: _____________________
Pleurodesis
Follow-up Check-up
Date of follow-up/Petsa ng Follow up Time/Oras Need to bring / Mga kailangang dalhin
06/09/2023 8:00 am DISCHARGE SUMMARY
Prepared by: Instruction given by:
ANDREW MEDFORD, MD
Phydician-in-Charge Nurse-on-Duty
**Dalhin ang dokumentiong ito sa petsa ng Follow-up
**Para sa karagdagang katanungan, maari kayong tumawag sa Alagang Pinoy helpline: (054) 471-6125
BMC-F-MED-001 Rev. No. 3 Effectivity Date: February 10, 2016
