Good morning ma'am.

Update on patient
RIVERA, DAVID
39/M/SSG/PN(M)

Dx: Acute Appendicitis, Suppurative

OR Done: Open Appendectomy (12 Aug 2019)

POD1
Patient is afebrile, has adequate pain control, no headache, nausea/vomiting,
difficulty of breathing. No flatus or BM.

Awake, conversant, not in distress

VS: 130/80, 37.7, 68, 20, 97%
Abdomen is flat, soft, tender around post-op site

Ti: 2325
To: 1225
UO: 0.72cc/kg/hr

P > NPO
continue IVF of PNSS 1L x 8H
continue current medications:
- Cefoxitin 1g TIV Q8H
- Omeprazole 40mg TIV OD while NPO
- Pain medications c/o Anesthesia service
- Paracetamol 300mg TIV now then Q6H PRN for fever
Monitor vital signs every 4 hours and record
Monitor input and output every shift and record
Refer accordingly

Thank you ma'am.

Good afternoon po. We have a new patient. Santos, Sanorjo 55/F/EDF/PN

14 days PTC, patient noted epigastric pain, 5/10, intermittent, crampy, radiating
to the RLQ. No Nausea, no vomitting, no anorexia, no dysuria, No consult was done,
no medication was taken.

Interval History showed intermittent episodes of the abdominal pain.

1 day PTC, patient then noted episodes of the abdominal pain which prompted consult
in MNH where he was started on D5LR and given omperazole. Patient was the sent to
VLMC for further Management.

Awake, alert.
120/70, 65BPM, 21 cpm, cpm, 36.8 temp
Anicteric sclerae symmetrical chest expansion
Flabby abdomen, soft, noted direct tenderness over the RLQ, no rebound tenderness,
no rovsings sign

CBC (12 Aug 19): Hgb 172, Hct 0.48, WBC 8.2 Seg 0.72, Lym 0.25, Plt 151

UA RBC 3-5, pus 0-2

a> t/c acute appendicitis

P>
NPO
IVF D5LR x8H
Urinalysis
CBC with PC

Thank you po sir.

Good afternoon ma'am. Update on Santos, Sanorjo 55/F/EDF/PN

RLQ UTZ: Non compressible, aperistalitic, tubular blind ended tubular structure
with periappendiceal fluid measuring 0.62cm.

Thank you po mam

Good afternoon maam. We have a new patient in the OPD

Osana, Nanet
44/F/EDW/PA

3 years PTC, patient noted 1x1 cm breast mass over the upper outer quadrant of the
left breast, with minimal tendereness, no skin changes, no nipple discharge. No
consult was done, no medication was given. Interval history showed progression in
the size of the mass. This prompted consult.

Interval history showed minimal breast tenderness, left, 1/10.

Breast mass left, upper outer quadrant, movable with well circumscribed borders,
approximately 7x7cm, with no skin changes ,no nipple discharge, (+) breast
tenderness, no cervical or axillary lymphadenopaties

No masses over the right breast.

Histopath (NKTI): Atypical Ductal Hyperplasia, Cannot Totally rule out a more
severe pathology

Breast UTZ: breast mass and nodules, left; BIRADS 4: Suspicious for malignancy,
Unenlarged lynphnodes with maligant features, left axillary.

A> breast mass, left

Good afternoon mam. We have evac from AGH patient VIRAY, REYNALDO 51/M/CPL

Known case of T/C Retained CBD Stone; S/P IOC Cholecystectomy with CBDE and T tube
insertion (14 March 2019) for Obstructive Jaundice secondary to
Choledocholithiasis; S/P ERCP with Stent Insertion

5 months PTA, patient abdominal discomfort describe as bulging sensation along the
post operative incision site. No accompanying symptoms such nausea, vomiting or
changes in BM.

During the interim, there was noted bulging along incision site which was gradually
progressing. Still no associated fever, nausea, vomiting, or changes in BM.

2 weeks PTA, patient had febrile episodes associated epigastric pain. No nausea,
vomiting, or changes in BM. Ciprofloxacin and Metronidazole were given which
provided relief of symptoms.

Patient came back as evac for ERCP and regarding Incisional Hernia.

120/80 105bpm 20cpm 36.5

Pink palpebral conjunctiva, anicteric sclera
Symmetrical chest expansion, clear breath sounds
Adynamic precordium, no murmur
Flabby, non erythematous, non hypertrophic scar, (+) bulge under incisional site,
NABS, soft, non tender
Pulses full and equal, no edema, no cyanosis

A: Incisional Hernia; S/P IOC Cholecystectomy with CBDE and T tube insertion (14
March 2019) for Obstructive Jaundice secondary to Choledocholithiasis; S/P ERCP
with Stent Insertion; T/C Retained CBD Stone

P:
Admit
Low salt low fat low cholesterol diet
Increase OFI
For CBCqPC, PT, PTT, Na K, Cl, FBS, Lipid Profile, ALP, TPSA
Urinalysis, 12LECG, CXR PA, HBT UTZ
Irbesartan 300mgtab 1 tab OD
Celecoxib 200mgtab 1 cap BID PRN pain
MVT 1 tab OD
Ascorbic Acid 500mgtab 1 tab OD
Follow up funding for ERCP
Refer to Genmed for preop risk evaluation prior to ERCP under IV sedation and
Repair of Incisional Hernia under GA

Good morning sir. We have an evac from 10ID. Rico, Honard 26/M/PFC/PA

10 days PTC, patient noted right lower quadrant pain, 5/10, intermittent, radiating
to the Epigastric area, crampy in character. No Jaundice, tea colored urine,
acholic stool. Consult was done in a private clinic where UTZ was done which showed
Calculous Cholecystitis. Patient was then sent home with HNBB and Tramadol.
Interval History showed intermittent pain episodes relieved by HNBB and Tramadol.
No jaundice, tea colored urine or acholic stool.

Patient was also advised to secure a ticket prior to Evac to VLMC.

Awake, alert, not in distress

120/90, HR 68, 20 cpm, T 36.8
Anicteric sclearae, pink palpebral conjunctivae,
Symmetrical Chest expansion, clear breath sounds
Flabby Abdomen, NABS, soft, non
tender, (-) Murphy's sign.
Grossly normal extremities

WAB UTZ (04 August): gallbladder is enlarged to 10.4x5cm with thickened walls up to
0.5cm, a stone is seen on the neck measuring 1.6cm,

A: Calculous Cholecystitis

Good evening mam. We have ER consult patient TAN, Euri Jay 16/M/EDS

Patient came in 3 hours post injury, patent airway, spontaneously breathing, no

active bleeding

NOI: Trauma
DOI: 12 Aug 2019
TOI: 2000H
POI Camp Aguinaldo

Patient was playing along outskirts of Camp Aguinaldo when patiwnt was hit in the
head by an allegedly steel bar. Patient initially tolerated the condition and
continued to head on home when he suddenly had loss of consciousness. No nausea,
vomiting, or changes in sensorium.

Skull APL, Cervical APL

No evidence of fracture, no cervical straightening

120/80 78bpm 20cpm 37.3C 98% 55kg

(+) Lacerated Wound, Frontal Area, Left, approximately 3cm, pink palpebral
conjunctiva, anicteric sclera
No external signs of injury to the chest and back, symmetrical chest expansion,
clear breath sounds
Adynamic precordium, no murmur
No external signs of injury to the abdomen, flat, NABS, soft, non tender
Pulses full and equal, no edema, no cyanosis

A: Mild Head Injury; Lacerated Wound, Frontal Area, Left secondary to Trauma (Steel
Bar)

P:
For Primary Wound Closure
Skull APL and Cervical APL done
Pedia referral
Tdap booster 0.5cc /IM
ATA 3000 IU/IM
Clindamycin 600mg TIV as loading dose then 300mgtab 1 tab q8 x 7 days
Paracetamol 500mgtab 1 tab q6 PRN pain
NS referral
No immediate surgical intervention warranted at the time of examination

Thank you mam Good evening mam. Update on patient TAN, Euri Jay 16/M/EDS case of
Mild Head Injury; Lacerated Wound, Frontal Area, Left secondary to Trauma (Steel
Bar)

P:
Primary Wound Closure done
For open mouth cervical xray
Medications:
Tdap booster 0.5cc /IM
ATA 3000 IU/IM
Clindamycin 600mg TIV as loading dose then 300mgtab 1 tab q8 x 7 days
Paracetamol 500mgtab 1 tab q6 PRN pain
Follow up at GS OPD 16 Aug 2019

Good afternoon sir. We have a referral from IM-ER patient Driz, Nichols
52/M/Commodore

3 days PTR, patient noted epigastric pain, 3/10, acidic in character, non
radiating, associated with persistent hiccups. No associated fever, nausea,
vomiting, dysuria or changes in BM. Consult was done in MNH where he was assessed
with Dyspepsia and was advised EGD. He was given Omeprazole which provided
temporary relief of pain.

Interval history showed perisistence of symptoms. Patient was admitted for EGD and
was referred for abdominal pain.

Presently no abdominal pain or tenderness

S/P Exploratory Laparotomy, Splenectomy

Known case of Cholecystholithiasis based from annual UTZ and was asymptomatic
Awake, alert, not in distress
120/80 82bpm 19cpm 36.7 98%
Pink palpebral conjunctiva, anicteric sclera
Symmetrical chest expansion, clear breath sounds
Flabby, (+)midline laparotomy scar, NABS, soft, direct tenderness epigastric area,
(-) Murphys
Pulses full and equal, no edema, no cyanosis, no jaundice

ECG: sinus rhythm

WAB Ultrasound (12 Aug 19): Liver is Enlarged with increased parenchymal
echogenicity. The right liver lobe measures 17.8cm while the left measures 8.3cm.
Gallbladder is normal in size (5.4x2.9x3.1cm). An intense echo with sharp posterior
shadowing is seen intraluminally measuring 1.6cm in its widest diameter. Intra and
extrahepatic ducts are not dilated. Both kidneys are normal in size and parenchymal
echogenicity. The prostate gland is Enlarged.

A> Dyspepsia prob secondary to acute gastritis, Cholecystolithiasis, Non Alcoholic

Fatty Liver disease,
Coronary Artery Disease 4 vessel disease; Hypertensive cardiovascular disease FC
II, s/p Percutaneous coronary intervention (2013), s/p exploratory Laparotomy,
spleenectomy (2014) secondary to speed boat accident.

A: Dyspepsia probably secondary to Acid Peptic Disease; Cholecystholithiasis; Non

alcoholic fatty liver disease; Coronary Artery Disease 4 Vessel Disease;
Hypertensive cardiovascular disease FC II, s/p Percutaneous coronary intervention
(2013) S/P Exploratory Laparotomy, Splenectomy (2014) for Vehicular Crash

P:
Continue present medical management
Suggest to do: cbc qpc, ua, hbt utz, flat plate, cxr pa, 12 L ECG
Suggest to give omeprazole 40 mg tiv OD, hnbb 20 mg tiv q6, tramadol 50 mg tiv q8
Secure gen med, cardio, gi clearance for elective cholecystectomy

Thank you sir

Good afternoon, ma'am. We have an Evac from Camp Tecson: LABARINTO, JERIC 22/M/CS
who was brought in due to infected wound, left axillary area.

14 days prior to admission, patient noted to have a carbuncle on the left axillary,
with no febrile episode. Wound was noted to resolve after 3 days. No consult done.
No medications taken.

7 days prior, there was noted appearance of multiple carbuncles at the left
axillary area, associated with febrile episodes. Patient sought consult, was
refrained from attending daily physical activites, and was advised wound care. No
antibiotic was given.

2 days prior, persistence of symptoms prompted consult at the dispensary where the
carbuncles were expressed with noted yellowish purulent discharge. Persistence of
lesions prompted transfer to our institution.

BP 120/70 HR 75 RR 19 T 37.2°C O2Sat 98%

(+) multiple, matted, tender nodularites, approx 1-2 cm x 1-2 cm in size at the
left axillary area, with crusting
No limitation of movement

A > Hidradenitis Suppurativa, Axillary Area, Left

Plan:
Admit at W5C
Diet as tolerated
Diagnostics:
- CBC with QPC
- Wound GS/CS
Medications:
- Cefuroxime 1.5 mg TIV as LD then 750 mg TIV q8hrs
- Celecoxib 200 mg cap BID