GENERAL SURGERY: TEAM I

DR. TAMANI/LINGAN/AGUISANDA/BACULI/CASCO/ BULUSAN/ padilla/soriano/ravivarma/raveendran/nagui/shanmugam/navalta/felix

JANUARY 22, 2020

TRAUMA MALE A
PATIENT DIAGNOSIS MEDICATIONS DIAGNOSTICS
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1Lx16hour E
TM-A INITIAL DX: DIET: DAT 1/102020

ANCILLARY:
MULTIPLE PHYSICAL
INJURY SECONDARY MEDICATION:
LEDESMA, EDGAR SERANO TO VEHICULAR 1. Losartan 50 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; MULTIPLE mg BID 1/06/20 15.3 151 0.43 75.2 16.9 7.2 0.4 0.3 267 102 36 350
53/M
RIB FRACTURE 3RD-5TH 2. Amplodipine
RIGHT CLAVICULAR 10 mg OD
FRACTURE RIGHT, 3. Ampi-sul 1.5
DOB:06/15/66 PULMONARY gm TIV q8
CONTUSION RIGHT 4. Salbutamol +
CHEMISTRY CREA BUN Alb Globu NA K CL FAS GLU CHOOL TRIGL HDL LDL ALT AST TB TP A/ CEA B1/B2
DOA: 01/06/20 Ipratropium lin E Y G
neb q6 1/11/20 28 27.80 60 94 221. 55 1.0 86.8/3
3 6.2
5. Nicardipine
drip: 90cc 1/09/20 6.10 3.43 0.77 0.94 2.14
CC: VEHICULAR ACCIDENT pNSS + 1amp 1/06/20 142. 4.06
Nicardipine to 1

run for 15 PT INR % Control PTT Control

HISTORY: gtts/min
1/11/20 13.20 1.06 90.4 34.3
NOI: VA
MONITOR VS q4 and
TOI: 6:30AM record
Monitor input and
POI: PENABLANCA, CAGAYAN output q shift

DOI: 01/06/20 PLAN:

Pull out CTT
16th hospital day Facilitate Chest UTZ
Continue incentive
spirometry`

Novi
TM-A
IVF: PNSS 1LX 8 HRS UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
Leukocyte RBC WBC EPITH HYALI BACTERIA
GUZMAN, JAY R DALUDADO INITIAL DX: DIET: DAT WITH SAP E

34/M MULTIPLE PHYSICAL MEDICATION:

INJURY SEC. TO VA, CELECOXIB 200MG/CAP
DOB: 01/21/20 MULTIPLE RIB BID FOR PAIN
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
FRACTURE 8TH TO SALBUTAMOL +
DOA: 1/21/20
9TH RIBS, RIGHT IPRATOPRIUM NEB 1/21/20 25.4 0.41 144 87.2 5.9 6.5 0 0.4 388 82 29 356

CC: VA TRAMADOL 50MG/ IV

Q8 FOR PAIN
NOI: VA CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA
ALBU GLOBU
AST ALT TB TP A/G CEA
PLAN: MIN LIN

TOI: 7:30 PM DAILY WOUND CARE 1/21/20 137.60 3.36

REPEAT CXR-PA AT 6 AM
POI: AMULUNG WOF: DOB,
DESTAURATION
DOI: 1/20/20 PT % INR
CONTR
APTT
OL

nd
2 Hospital stay 1/21/20 13.40 95.20 1.04 30.10

NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x KVO E
TM-A INITIAL DX: DIET: Diet for age

MULTIPLE PHYSICAL
ANCILLARY: CTT output
INJURY SECONDARY
CATAGGATAN, MIYA CALATA 400cc
TO VEHICULAR
ACCIDENT CEREBRAL MEDICATION:
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
33/M
CONCUSSION LINEAR 1. Ampicillin-
1/20/20 20.1 94 0.27 80 16 3.5 0 0.2 510

DOB: 10/24/2019 SKULL FRACTURE Sulbactam 162.5g

FRONTAL RIGHT IV q6
DOA: 01/20/2020 2. Paracetamol
90mg/IV
CC: VEHICULAR ACCIDENT 3. Ranitidine CHEMISTRY CREA BUN AMY LIP NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
ASE
6.5mg/IV 1/20/20 135.50 4.41
4. Ampicillin
HISTORY: Sulbactam
170mg/IV PT % INR CONTROL APTT CONTROL
NOI: VA
MONITOR VS q4 and
record
TOI: 8PM

POI: CABAGAN ISABELA PLAN:

Carry out pedia notes
DOI: 01/20/2020 WOF neurodegeneration
Continue Antibiotics
2nd Hospital day

TM A INITIAL DIAGNOSIS IVF: D5LRS 1L X 8 HRS NITRAT

UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: SOFT DIET WITH E
SORBANO JOHNNY URANI EPIDURAL SAP
HEMATOMA RIGHT,
42/M FRONTOTEMPOROPA MEDICATION: Mannitol
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
RIETAL 150cc/IV
DOB: 4-7-1977 1/18/20 20.8 138 0.40 89.7 3.6 6.6 0.0 0.1 287 92 32 342
INTRACEREBRAL Ceftriaxone 2g/IV
DOA:1/15/20 HEMATOMA RIGHT Omeprazole 40mg/IV
FRONTAL Ketorolac 30mg/IV
CC: Vehicular Accident SECONDARY TO Ascorbic acid 500mg/
VEHICULAR tab
NOI:VA ACCIDENT B complex tab

TOI:3PM PLAN:
Facilitate Optha orders
DOI:1/15/20
Decrease Mannitol
120cc/IV q6
POI: TUMAUINI
Daily wound care
7th HOSPITAL STAY

Trauma Male B
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L X 8hr E
TM-B INITIAL DX: DIET: DAT with SAP 1/10/2020 LY Clear 1.015 7.5 - - ++ - - - - - 86 2 1 0 7

ACUTE EPIDURAL ANCILLARY:

HEMATOMA, RIGHT MEDICATION: Ampicillin-
LAURETA, REYNARD CALMA FRONTOTEMPOROPA Sulbactam 1.5g/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
RIETAL LEFT; Omeprazole 40mg/IV 1/14/ 20 10.9 107 0.31 82 9.7 5.8 2.2 0.3 231 93 33 351
FRONTOTEMPOROPA Tranexamic Acid
RIETAL; SKULL 500mg/IV
FRACTURE LEFT Ketorolac 30mg/IV
DOB:Oct 18 1999 FRONTAL;
NEUROCEPHALOUS
CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOA: 01/10/20 MONITOR VS q4 and
record 1/14/20 135.1 2.97
CC: VA Monitor input and
1/13/20 138.30 3.57
output q shift
22th HOSPITAL DAY
PLAN: PT INR % Control PTT Control

Daily wound care

Bincey continue meds 1/13//20 13.30 30.30
decrease manitol to 75cc
q8 x 3 cycles then d/c
Facilitate Correction of
potassium

NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L X 12hr E
TM-B INITIAL DX: DIET: DAT with SAP 1/16/2020
DARK
Clear 1.020 7.5 - Trace Trace - - + - - 33 258 2 0 31
YELLOW

ANCILLARY:
 INTRAPARENCHYMAL MEDICATION:
BLEED PROBABLY toclopramid 10mg/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ATTABAN, EDRIEL APOSTOL SECONDARY TO Ceftriaxone 1g/IV
1/19/ 20 9.3 119 0.37 50 25 8.7 14.4 1.0 327 62 20 320
ARTERIOVENOUS Paracetamol 300mg/IV 1/21/20 12.4 125 0.40 52.8 21.4 6.9 18.3 0.6 447 63 20 313
17/M Mannitol 120cc/IV q4
MALFORMATION
DOB:Feb 28-2002 MONITOR VS q4 and
record
DOA: 01/10/20 CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
Monitor input and
CC: output q shift 1/16 72 131 3.78

12th HOSPITAL DAY PLAN: 1/21/20 137.80 4.33

awaiting MRI result

Continue medications PT INR % Control PTT Control

1/19//20 13

TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT

UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
MASCARINAS, CLARENCE JESSIE ACUTE EPIDURAL 1/18 LY CLEAR 1.030 6.5 - - ++ - - + - - 8-10 2-3 - - +

CORTEZ HEMATOMA, ANCILLARY:

FRONTOTEMPOROPA
6/M RIETAL RIGHT MEDICATION:
SECONDARY TO FALL Ampicillin-Sulbactam CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 05/8/2013 1.5g TIV q8 1/18 7.6 103 0.30 62 31 5.4 0.4 0.7 344 80 28 344
Ketorolac 30 mg IV q8
DOA: 01/18/20
PRN for pain
CC: FALL Omeprazole 40 mg TIV
q24
NOI: FALL CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
Monitor VS q2 and ISTRY SE MIN LIN G
TOI: 10PM record 1/18 140 4.26
Monitor I & O qshift and /20
POI: ILAGAN ISABELA record PT INR % Control PTT Control
PLAN:
DOI: 1/18/20 Continue medical 1/18/2020 14.50 39.80
management
4th HOSPITAL DAY WOF neurodegeneration

TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT

UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
LAWAGAN, BRYAN GARRO MULTIPLE PHYSICAL 1/18 LY CLEAR 1.030 6.5 - - ++ - - + - - 8-10 2-3 - - +

INJURY SECONDARY ANCILLARY:

20/M TO VA, MINIMAL
ACUTE SUBDURAL MEDICATION:
DOB: 05/11/1999 Ceftriaxone 1gm/IV
HEMATOMA RIGHT CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
PARIETAL LINEAR Omeprazole 40mg/IV
DOA: 01/18/20 1/18 10 102 0.31 72 19 7 0.1 0.3 301 90 30 330
SKULL FRACTURE, Ascorbic acid 40mg/IV 1/20 8.6 100 0.29 69.3 22.2 8.1 0.2 0.2 295 89 30 341

CC: VEHICULAR ACCIDENT RIGHT PARIETAL, Mannitol 100cc/IV

PNEUMOCEPHALUS, Gentamycin 240mg/IV
NOI: VA OPEN FRACTURE LEG Pen G 5 milli units
TOI: 8AM LEFT Monitor VS q2 and CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
record
1/18 139 4.49
POI: TUMAUINI ISABELA Monitor I & O qshift and /20
1/20 139.40 4.49
record
DOI: 1/18/20 PLAN:
Maintain mannitol 75cc PT INR % Control PTT Control
4th HOSPITAL DAY q6 with BP precaution
1/18/2020 14 27
WOF neurodegeneration

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: NPO E
MEDALLA. ERICKSON ACUTE SUBDURAL MEDICATION:
HEMATOMA, LEFT Ampicilin-Sulabctam
18/M PARIETAL AREA 1.5g IV q8
SECONDARY TO Omeprazole 40mg/IV
DOB: 11/18-2001 Mannitol/100cc/IV
VEHICULAR CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

ACCIDENT ketorolac 30mg/IVq8 1/21 26 158 0.47 89 4.5 6.6 0 0 390 90 30 338
DOA: 01/20/20

CC: VEHICULAR ACCIDENT PLAN:

repeat cranial CT Scan
NOI: VEHICULAR ACCIDENT Daily wound care CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

WOF neurodegeneration
TOI: 9PM 1/21 139.10 4.08
hook to 02 support at 2-
3LPM via NC
DOI: 1/20/20
PT INR % Control PTT Control
2ndHospital stay
1/21 14.30 32.20

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
SARDON, NESTOR CAMAGON MULTIPE PHYSICAL
INJURY SECONDARY MEDICATION:
46/M TO VEHICULAR Mannitol 150cc/IV
ACCIDENT, Diphenhydramine
DOB: 8/16/73
CONTUSION 50mg/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

DOA: 01/16/20 HEMATOMA RIGHT KCL drip: 90ccPNSS 1/19/20 9.5 94 0.27 87 6.6 5.1 0.1 0.3 222 90 32 352

TEMPOROPARIETAL +10meqs KCL

CC: VEHICULAR ACCIDENT ACUTE EPIDURAL
HEMATOMA LEFT PLAN:
NOI: VEHICULAR ACCIDENT PARIETO-OCCIPITAL Decrease mannitol CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

TRAUMATIC Start N-acetylcysteine

TOI: 10PM 1/20/20 3.52
SUBARACHNOID hook to 02 support
1/19/20 136.40 2.88
HEMORRHAGE may transfer to surgery
DOI: 1/16/20
ward
PT INR % Control PTT Control
POI: STA TERESITA

6TH Hospital stay

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: Low fat low salt E
DOMINGO NORMAN MULTIPLE PHYSICAL diet 1/20/20 YELLOW HAZY 1.020 6.5 - ++ + - - + - - 5-8 3-5 FEW

INJURY SECONDARY
19/M TO VA, ACUTE MEDICATION:
SUBDURAL Ampicilin-Sulabctam
DOB: 1/20/2000
HEMATOMA RIGHT 1.5g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

DOA: 01/20/20 FRONTOTEMPOROPA Mannitol 150 cc IV q4 1/20 25 137 0.42 86 4.6 8.4 0 0.2 269
RIETAL WITH with BP precaution
CC: VEHICULAR ACCIDENT INTRACEREBRAL Ketorolac 30 mg/IV q8
HEMATOMA PRN for pain
NOI: VA BIFRONTAL AREA, Kcl drip: 900cc PNSS +
SUBARACHNOID 10 meqs Kcl x 1 hr x 2 CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
TOI: 12AM HEMMORHAGE cycles
1/14/20 136.40 3.71
DOI: 1/20/20
PLAN: 1/18/20 136 3.49

2nd Hospital stay Insert IFC and NGT

Secure 2 units PRBC PT INR % Control PTT Control

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: Low fat low salt E
BALANAY, ERNESTO BIGGAYAN CONTUSION diet 1/102020

HEMATOMA, LEFT
68/M TEMPOROPARIETAL MEDICATION:
AREA Ampicilin-Sulabctam
DOB: 10/15/1951
1.5g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

DOA: 01/14/20 Mannitol 150 cc IV q4 1/14/20 25.1 128 0.38 88.2 3.7 8.7 0.1 0.2 230 90 31 338
1/18/20 10.8 131 0.38 68 14 5.8 10.7 0.7 351 89 31 346
with BP precaution 1/21/20 15.5 140 0.41 70.4 12.3 6.0 10.8 0.5 427 90 31 343
CC: LOC Ketorolac 30 mg/IV q8
PRN for pain
NOI: FALL Kcl drip: 900cc PNSS +
10 meqs Kcl x 1 hr x 2
TOI: 7 PM cycles CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

Salbutamol + Iprat neb

DOI: 1/06/20 q8 1/14/20 136.40 3.71

1/18/20 136 3.49

8thHospital stay
PLAN: 1/21/20 134.40 3.38

Decrease mannitol to
150cc/IV q6 PT INR % Control PTT Control

Continue medications

TM-B INITIAL DX: IVF: D5LRS 1L X 12 HRS NITRAT

UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
DIET: DAT with SAP E
ESTABILLO, ARIEL CABANSAG MULTIPLE PHYSICAL
INJURY SECONDARY MEDICATION: Mannitol
TO VEHICULAR 150cc/IV
19/M ACCIDENT. MINIMAL Ceftriaxone 2g/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACUTE SUBDURAL Omeprazole 40mg/IV 1/18/20 20.8 138 0.40 89.7 3.6 6.6 0.0 0.1 287 92 32 342
DOB: 01/16/2001 HEMATOMA, RIGHT Ketorolac 30mg/IV
FRONTAL SKULL Ascorbic acid 500mg/
DOA: 01/18/2020 tab
FRACTURE FRONTAL
AREA B complex tab
CC: INGESTION OF ZONROX
CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
4th Hospital stay PLAN: ISTRY SE MIN LIN G

Continue Medications 1/18 135 3.85

/20
WOF nuerodegeneration 1/21 4.32

PT INR % Control PTT Control

1/18/20 15.50 40.10

AISLES RIGHT
CRITICAL CARE ROOM
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 12hrs E
CCR INITIAL DX: DIET: NPO

MULTIPLE PHYSICAL ANCILLARY:

INJURY SECONDARY
AGRIAM, MARY ROSE SOSA TO VEHICULAR MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT,
42/F 1/18/20 19.6 120 0.34 91.8 3.8 4.3 0 0.1 161
TRAUMATIC
DOB:12/18/1977 SUBARACHNOID MONITOR VS q2 and
HEMORRHAGE record CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA

DOA: Jan 18 2020 SECONDARY TO Monitor input and

59 145 3.88
VEHICULAR output qshift
CC: Vehicular Accident ACCIDENT PT % INR CONTROL APTT CONTROL
1/18/2020 18.70 35.60
PLAN:
NOI: Vehicular accident Continue Meds
prognosticated
TOI: 3pm Secure form for DNR

DOI: 1/18/20

POI: CLAVERIA, CAGAYAN

4th HOSPITAL DAY

IVF: PNSS 1Lx 8 hrs NITRAT

CCR INITIAL DX: DIET: OF feeding
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
E
Leukocyte RBC WBC EPITH HYALI BACTERIA

JARA, JUDY JR SEATRIZ T/C BRAIN ABSCESS,

ANCILLARY:
RIGHT
34/M CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
FRONTOTEMPORAL
MEDICATION 1/14/20 9.7 159 0.46 71.9 19.6 7.2 1.1 0.2 322 85 30 348
Ceftriaxone 2g IV q12
DOB: 04/29/1985 S/P E' CRANIECTOMY, Vancomycin 1g IV q12
RIGHT EVACUATION Ketorolac 30mg IV q8
DOA: 01/14/20 OF HEMATOMA FOR PRN for pain
ACUTE EPIDURAL
CC: GENERALIZD BODY WEAKNESS CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
HEMATOMA, PLAN:
TEMPORO-PARIETAL, Continue oral feeding 1/15/20 75.20 136.8 4.08 93
.6
(+) HEADACHE RIGHT WITH Continue medications
DEPRESSED SKULL WOF any problems PT % INR CONTROL APTT CONTROL
(+) DIZZINESS FRACTURE , RIGHT 1/14/20 14.80 1.17 75.80 25.80
FRONTOTEMPOROPA
(+) N/V RIETAL SEC. TO VA ESR: 24mm/hr

8th Hospital stay

AISLES LEFT
TRAUMA FEMALE A
PATIENT DIAGNOSIS MEDICATIONS DIAGNOSTICS
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1 L X 12 HRS E
TF-A INITIAL DX: DIET: DAT with SAP
CAPINLAC, ROMAN BASA CONTUSION
ANCILLARY: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
HEMATOMA, RIGHT
58/M
FRONTOTEMPORAL 1/15/20 10.8 169 0.46 73 17 8.8 0.1 0.8 212 81 30 365
MEDICATION
DOB: 11/20/1963 AREA SEC. TO FALL
Ampicillin- Sulbactam
1.5 g IV q8
DOA: 01/15/2020
Mannitol 150 cc q4
Ketorolac 30 mg q8 IV
CC: LOC CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
PRN for pain
1/15 133 3.24
NOI: FALL
PLAN: 1/16 13.30 5.04 1.37 1.29 3.12
TOI: 5PM Increase mannitol PT % INR CONTROL APTT CONTROL
120ccq4 1/15/20 13.50 27.10
DOI: 1/12/20 Continue Medications

POI: ISABELA

7th HOSPITAL DAY

NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 16hrs E
TF-A INITIAL DX: DIET: DM DIET 1/10/2020

MULTIPLE STAB ANCILLARY:

WOUND 8TH
ARNEDO, SEVERINO GALARCE INTERCOSTALS MEDICATION:
57/M SPACE, RIGHT. LEFT Human Albumin, 1 Vial CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
UPPER QUADRANT. to run for 6hours q12 1/09/20 11.3 96 0.28 88 6.8 4.3 0.6 0.3 345 83 29 347
POSTERIOR ARM,
LEFT MONITOR VS q2 and
record
CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
Monitor input and
DOB:07/26/1967 output qshift 1/09/20 3.63 142.61 98.64

DOA: 1/12/2020 4.11

PLAN:
1/14/2020 21 26.30 47 0.8
CC: Stab wound Wound Flushing q12 0
Encourage ambulation PT % INR CONTROL APTT CONTROL
Give paracetamol 1g/IV
Jesserene Apply ice pack to Left
arm

TRAUMA FEMALE B
IVF: PNSS 1L 8hours UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRITE Leukocyte RBC WBC EPITH HYALI BACTERIA

TF-B INITIAL DX: DIET: DAT with SAP DY Hazy 1.010 7.5 - TRACE + - - - - 24 5 1 1
-

PNEUMOHEMOTHOR ANCILLARY:
AX SECONDARY TO CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
LIZARDO, EDUARDO JR. UBERITA STABWOUND MEDICATION: 1/07/20 14.3 115 0.35 64.5 14.7 10.0 10.4 0.4 360 90 30 329
1/9/2020 16.2 131 0.40 70 13.7 13.3 2.6 0.4 256 88 29 328
ANTERIOR CHEST 6TH 1. Celecoxib 1/15/20 17.6 132 0.39 65.4 19.2 7.2 7.5 0.7 474 86 29 336
22/M
INTERCOSTAL SPACE 200mg/cap, 1
MIDCLAVICULAR LINE cap BID PRN
LEFT for pain
DOB:09/08/97 2. Salbutamol
neb q6
DOA: 01/09/20 3. Ampicillin-
Sulbactam CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
1.5g IV q8
1/07/20 134.30 4.16
CC: STAB WOUND 1/15/20 136.10 4.15
PLAN: PT % INR CONTROL APTT CONTROL
REMOVAL OF CTT
HISTORY:

NOI: STAB WOUND

TOI: 11PM

POI: LASAM, CAGAYAN

DOI: 11/07/20

12th HOSPITAL DAY

POST OP DAY 10

bincey
 IVF: PNSS 1L 12hours UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRITE Leukocyte RBC WBC EPITH HYALI BACTERIA

TF-B INITIAL DX: DIET: DAT with SAP DY Hazy 1.010 7.5 - TRACE + - - - - 24 5 1 1
-

MULTIPLE PHYSICAL ANCILLARY:

INJURY SECONDARY
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
CORPUZ, JERICO MACAPAGAL TO VEHICULAR MEDICATION: 1/20/20 10 121 0.36 64 26 6.7 2.3 0.5 553 84 28 334
ACCIDENT, ACUTE 4. Ceftriaxone
16/M
EPIDURAL 1g/IV
HEMATOMA 5. Ketorolac
PARIETOOCCIPITAL 3mg/IV
DOB:09/17/2003 AREA RIGHT; 6. Mannitol CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA

PNEUMOCEPHALUS 100cc/IV q8 1/20/20 136.70 3.68

DOA: 01/20/20 LINEAR SKULL 7. Paracetamol
PT % INR CONTROL APTT CONTROL
FRACTURE 1g/IV
8. Tranexamic
Acid1g/IV
CC: Vehicular accident

PLAN:
HISTORY: Start Ascorbic acid
500mg OD
NOI: VA
Shift mannitol 100cc q8
TOI: 12am WOF neurodeterioration

POI: Mallig Isabela

DOI: 11/20//20

3RD HOSPITAL DAY

NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1Lx KVO E
TF-B INITIAL DX: DIET: DAT c SAP 1/10/2020

MULTIPLE STAB ANCILLARY:

WOUND 1) 5TH
DOQUES, MABINI JR ESCOBAR INTERCOSTAL SPACE CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
PARASTERNAL AREA, MEDICATION: 1/06/20 23.1 93 0.28 72.2 13.4 7.1 6.9 0.4 1049 82 27 333
25/M
RIGHT 2) 10TH 1/12/20 17.5 99 0.30 69.2 15.2 6.9 8.2 0.5 951 84 27 342
1/15/20 17.3 106 0.33 67.4 14.3 7.5 10.3 0.5 925 85 27 320
INTERCOSTAL SPACE
1/19/20 14.8 118 0.36 62 15 8.2 14.1 0.5 667 82 27 324
MAXILLARY LINE PLAN:
Daily CTT Care
Continue incentive CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOB:11/ 14/ 1994 spirometry 1/06/20 133.10 4.57
REPEAT CBC
DOA: 12/ 26/ 2019 1/12/20 61.60 137 4.26

1/19/20 62 136 3.96

CC: stab wound
PT INR % Control PTT Control
27th hospital stay
1/12/20 12.40 31.60
bincey
1/19/20 13.20 54.50
ISOLATION
GS1
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PLRS1L x 8HRS E
GSI INITIAL DX: DIET: DAT 1/13 LY Hazy 1.030 6 - - - - - - - - 4 1

ACUTE APPENDICITIS ANCILLARY:

BAJET BENJAMIN DE LEON MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
1.
58/F 1/16 13.1 148 0.43 85 8.8 3.4 1.5 0.4 246

MONITOR VS q4 and
record
DOB: NOV 20 1961 Monitor input and
output qshift
CHEMISTRY CREA BUN AMY LIPAS NA K C FAS GLU CHOOLE TRIGLY HDL AST ALT AL TP A/G CEA
DOA: 1/16/2020 E L P
PLAN: 1/19 78 139 3.51
S/P appendectomy
1/16 25 32
Continue present
CC: RUQ PAIN medication PT % INR CONTROL APTT CONTROL

REMOVE DRAIN

6TH hospital day

OVERFLOW

NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PLRS1L x 8HRS E
OF INITIAL DX: DIET: DAT 1/13 LY Hazy 1.030 6 - - - - - - - - 4 1

PAROTID MASS ANCILLARY:

MACANAN, NOEL VINASOY MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
2.
49/F 1/13 10 156 0.48 59 28 4.4 7.2 0.6 279

MONITOR VS q4 and
record
DOB: DEC 21 1970 Monitor input and
output qshift
CHEM CREA BUN AMY LIPA NA K CL FAS CHO TRIG HDL LDL ALT TB TP A/ CEA
DOA: 1/13/2020 ISTRY SE GLU OLE LY G
PLAN:
Continue Meds

CC: NECK MASS PT % INR CONTROL APTT CONTROL

HISTORY:

9th hospital day

luis

URO
GS3

CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

IVF: PNSS 1L x12hrs
GS-3 INITIAL DX: DIET: DAT with SAP 1/16/20 17 123 0.37 67 20 10 2 0.3 297 89 30 332

ANCILLARY:
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
E
GATCHALIAN, CHRISTYN KHEY INTRACRANIAL MASS MEDICATION: ½/2020 LY CLEAR 1.030 6.5 - - + - - + _ _ 7 25 29 0 446
ADIAZ INTRAVENTRICULAR 1. Cefuroxime
150mg/IV
17/M
2. Ranitidine 1
amp CHEMISTRY CREA BUN AMY LIPA NA K CL M CA ALBUM GLOBULIN AST ALT TB TP A/G CEA
3. Dexamethaso SE G IN
1/06/20 70.60 139 3.41 92
DOB:12/15/2002 ne 4g/IV
4. paracetamol PT % INR CONTROL APTT CONTROL

DOA: 01/02/2020 300mg/IV

MONITOR VS q4 and
record
CC: abdominal pain Monitor input and
output qshift

20th hospital stay PLAN:

NEURO MGH
jesserene
Awaiting MRI result

DISCHARGES
ALLAG

GUMARANG