Академический Документы
Профессиональный Документы
Культура Документы
September 4, 2015
Vasay/Castaeda/Carrillo
Admissions: 3
Referral: 0
Mortality:0
In Patients:31
Discharges:5
Absconded:0
HAMA:0
THOC: 0
th
rd
JC OPD 472/475 | 4 396/397 | 3 381/382 |KTU/EXT 383/384 | DW 386/387 | JC 478/479 | HW 469/589 | ICU 393/394/395| CVU 388/389 | CVU/EXT 486/487 | ER 166/163 | LAB 151/152/153 | XRAY 159/160 | NICU 213/214 | Pedia
313/314/428 | Dr. Abrigo 8713091/8927874 | Dr. Anchores 8713722 | Dr. Balasbas 9748775 | Dr. Cabrera 3431586 | Dr. Codeniera 8265317 | Dr. Colasito 9093120 | Dr. Crisostomo 8436395/8193863/2119142 | Dr. Dideles 8461327 | Dr. Dino
8752276/8720349 | Dr. Gatmaitan 8057585 | Dr. Llamas 4786211/8077991 | Dr. Malate 8713080 | Dr. Manalad 8360797/8753571/8748087 | Dr. Principe 3306090 |Dr. T. Miranda 874928 | Dr. T. Reyes 8727532/8711521 | Dr. A. Salonga 8713130/8788278 |
Dr. Teves 8427650/8711523 | Dr. Valdez 8421031 | Dr. Villanueva 9232581 | POISON CONTROL- 524/1078/1075/55218430 loc 231
Jonelta (3)
6C
9/3/15
2:47 PM
597853
Referral for
Pedia
Clerance and
Comanagement
6A
9/3/2015
1:50 PM
610371
MORALES,
Chelsie Ong
4M 10D/F/6.8kg
4/23/15
Pamplona 3,
LPC / Cavite
CAJURAO,
Henry Baltazar
10M 2D/M/8.6kg
Abscess Medial
Aspect of left arm
JC
YasayRonquillo
AGE with
Moderate signs of
dehydration
JC
Edornie
Garcia
11/01/2014
Gandara, Samar
/ Ermita, Manila
MAPUTOL,
Rosemarie
14/F/46kg
9/27/2000
Molino, Bacoor
Cabrera
6G
9/3/2015
4:03 PM
577056
T/C Periodic
Flaccid Paralysis
JC
Abrigo/
Salonga
Spinal Cord
Syndrome VS
Myopathy
D5 NM 1L X 12 hrs
Binos
UA 9/2: str/c/8.0/neg/neg/1.000/0-2/0-2/few/rare
CXR APL 9/2: NCATS
Wound discharge gs: pus cells: +3; g+cocci in
singles, in pairs and in chains: +2
UA: ly/h/6.0/-/-/1.010/2-4/0-2/e-occ/b-rare/mt-rare
SE:y/s/-gb/-m/-op/ fat globules seen
Cl: 108 (98-107)
K: 4.0
Na: 135 (137-145)
UA ty/h/6.5/-/-/1.025/0-2/1-3/few/mod
Na 139
K 4.4
Ca 1.07
CPK Total: 69.1
X-ray Thoracic and Lumbar: No demonstrable
evidence of fracture; Mild dextroscoliosis of
thoracic spine; Lumabar curvature is straightened
likely sec to muscle spasm; Posterior disc space
bet L5-S1 is narrowed; The rest of intervertebral
disc spaces, vertebral body heights and post
elements are intact.; The included sacroiliac joint
spaces are unremarkable; Incidental note of
generalized ileus.
EMG/CMV_______________________________
th
4 MAIN (8)
402
9/2/2015
2:57 pm
413152
Bonzo
SANTOS, Adriela
Ysabel F.
4/F/17kg
11/16/2010
Bacoor, Cavite
Interstitial
Pneumonia,
BAIAE
Pneumonia mod
risk
PP
Barza
405-A
9/1/15
2:15 am
276775
Cabrera
PITAO, Jervis
Angelo
12/M/54 kg
02/19/2003
LPC
PPI
Fuentes
CC: fever
3 wks PTA, (+) cough nonproductive, (+)
undocumented fever. No consult done, noe meds
2 wks PTA, (+) persistent cough given Clarithromycin
for 1 week, with relief
1 day PTA, cough recurrence productive, (+)
undocumented fever, given Paracetamol, noted relief
Morning PTA, (+) slight DOB, with retractions, neb
started with Budesonide and Ipratropium br, affording
slight relief. (+) 1 episode of vomiting noted after
giving cefuroxime, due to persistence of symptoms
brought to ER, subsequently admitted
CBC 9/4 4.96/.39/130/12.4/.74/.04/.15/.07/285
CC: vomiting and LBM
2 days PTA, patient had 2 episodes of vomiting of
PIF and 3-5 episodes of brownish watery stools, non
bloody non mucoid, NFS. With noted abdominal pain.
1 day PTA, persistence of vomiting of PIF (2x) and
LBM (3-5x). still with abd pain. No fever. Few hours
PTA, persistence of symptoms prompted ER consult
was subsequently admitted.
UA dy/st/6.0/tr/-/1.030/6-8/0-2/rare/few/mod
Fecalysis: yb/w/-gb/-m/none seen ova
406-A
9/3/2015
4:52 PM
466415
TRINIDAD,
Hoaquin
8/M/21kg
URTI
HCI
Barza
5/22/2007
LPC
Binos
D50.9 NaCl 500 cc x 79 cc/hr D5 NM
52-53 cc/hr
406-B
9/2/2015
8:04 pm
427190
Bonzo
MUDANZA,
DjhalzDazner L.
14/F/34kg
DFS DHF I
PPI
Principe
08/12/2001
LPC
AFABLE, Maurize
Carlino Guamos
1/M/12kg
HFMD
PPI
MendozaMedrano
Carrillo
Cabrera
TATLONGHARI,
Chloe Isabelle L,
1/F/12 kg
PPI
Viola/
Salazar
10/11/2013
LPC
430
8/31//2015
9:27 am
610082
ROQUE, Venice
Margaux
6m27d/F/8kg
2/4/2015
Pasay City/LPC
Binos
UA: ly/h/6.5/neg/neg/1.010/0-3/2-4/rare/few
UA: s/h/7.0/-/-/1.015/3-5/0-2/rare
CC: rashes
10/22/2013
LPC
360 417
9/2/2015
7:42 am
606497
D5 LR 1L x 7H
DTR
409
9/4/15
2:37pm
577243
CBC: 3.99/0.35.115.8.6/0.63/0.02/0.23/0.12/290
Pneumonia, Mod.
Risk
Measles
PPI
Viola/
Salazar
UA : ly/c/6.5/1.010/-/-/0-1/0-2/ec-rare
CXR (o): Interstitial Pneumonia
CBG 153 mg/dl
Na 136 N
K 5.0 N
Cl 101 N
Mg 0.98 N
UA: ly/h/6.5/-/-/1.015/0-2/1-3/rare/rare
CXR APL(o): NCATS
442
9/2/2015
2:35 pm
417360
Binos
MEJALA, Prince
Joshua P.
4/M/15kg
BAIAE, PCAP C
PPI
Viola/
Salazar
01/22/2011
LPC
UA dy/h/6.0/trace/neg/1.030/1-2/5-7/few/mod
CXR AP (o): NCATS
CBG 73 mg/dl
Na 140 N
K 4.3 N
rd
3 MAIN (8)
CVU13-A
302B
9/2/2015
11:44 pm
189129
AIZAWA, Megumi
P.
12/F/38kg
DFS
PP
Principe
06/15/2003
LPC
D5 LR 1L x 114cc/hr D5 LR 1L x 6
hours
CC: Fever
1 day PTA, in the afternoon, noted undocumented
slight fever. At around evening, documented temp at
38.5 C, patient given Paracetamol 500mg tab, noted
relief of fever after 30 mins. There was also note of
abdominal pain. Patient denies vomiting or bleeding.
Noted BM of watery yellow stool.
Few hours PTA, consulted with AP, and request for
NS1 given, noted positive result, and they then went
to ER, and patient subsequently admitted.
CBC 9/4 AM: 4.53/.38/126/12.0/.70/.04/.17/.09/298
CBC 9/4 PM: 4.36/.37/121/9.9/.72/--/.18/.10/324
Bonzo
302 C
9/4/15
8:52am
437269
VELARDE,
Emmanuel Louis L.
4/M/23kg
T/C
Appendicitis
Functional
Constipation
BANIAE, URTI
PPI
Principe
Fleet enema
D5 LR 78 cc/hr 65cc/hr
12/25/2010
LPC
Bonzo
312
9/2/2015
10:18 am
508509
JUNIO, Robin C.
2/M/14kg
PPI
Codeniera
05/05/2013
LPC
Binos
303
9/1/15
8:47PM
605202
MALIMUTIN, Brielle
Nicole
2/F/11kg
2/14/2013
Acute
Bronchitis;
Acute
Conjunctivitis
PP
Custodio
UA: y/h/6.0/tr/-/1.025/0-2/4-6/ec-few/b-mod
Abd xray (o): mild ileus
Whole Abd UTZ: Normal L,GB,P S and K; Non
dilated ureters; Probe elicited tenderness both
lower quadrants, Neg for intraperitoneal fluid
collection
UA y/h/6.0/neg/neg/1.020/0-1/3-4/rare/occ
CXR (o): Interstitial Pneumonia
DNS1 Ag neg, IgM neg, IgG neg
UA:ly/h/6.0/-/-/1.010/0-1/0-2/ecocc/bacte rare
CXR APL (o): NCATS
LPC
Salbutamol neb q8
Carrillo
D5 0.3 NaCl x 41-42cc/hr
Still MGH
307
9/2/2015
4:09 pm
523423
Bonzo
NEPOMUCENO,
Christian Keith S.
1/M/11kg
Simple Febrile
Seizure
PPI
Principe
11/28/2013
LPC
Combivent 1 neb q4- DC
O2 at bedside
Diazepam 1.1mg IV for frank seizure
Cetirizine syrup 3.5ml BID
D5 IMB 500cc x 35 ugtts/min
308
9/2/2015
8:32 pm
489075
Bonzo
SAN MIGUEL,
Jayden Sayen M.
2/M/13.5kg
PP
Aseron
08/16/2013
LPC
327A
9/2/2015
7:45 pm
610306
Bonzo
327-C
9/2/2015
6:05pm
467314
Bonzo
COTEJAR,
Princess Eiram C.
5/F/17.8kg
DFS
PPI
Principe
Na 134 N
K 4.3 N
UA ly/h/6.0/trace/neg/1.020/1-2/8-12/ecocc/bacte
rare
UA dy/h/6.0/t/-/1.030/rbc/1-3/3-5/few/rare
CC: fever
2-3 days PTC, patient complained of occasional
throat itchiness, no consult done nor medications
given
Morning PTA, noted increase in temp, given Calpol
drops 2ml, noted temporary relief.
5 hours PTA, noted another fever episode given
Paracetamol but this time with no noted fever relief.
3 hours PTA, they sought consult to AP and was
advised admission.
CBC 9/2 5.09/.39/134/14.9/.83/-/.10/.07/423
CBC 9/3 5.2/.4/136/7.7/.52/.01/.35/.12/346
CBC 9/4: 5.15/.41/132/5.5/.53/.01/.39/.07/325
D5 LR 500cc x 75cc/hr
08/24/2010
LPC
YUMOL, Stephany
Benette E.
18/F/50kg
CC: fever
1 week PTA, (+) occ cough, with whitish sputum,
given tsp, of Robitussin.
1 day PTC, still with occ cough, now with assoc.
undocumented fever, given Paracetamol (Tempra)
250/5 5ml, which afforded only slight relief, and
headache.
Morning PTA, noted temperature of 39 C, patient
brought to ER and noted temp of 38.2. Patient
subsequently admitted.
DFS
HCI
Llamas
09/26/1996
Pque
CC:fever
3 nights PTA, noted undocumented fever, no
medication was given. (+) abdominal pain, headache.
2 days PTA, documented tem at 38.4 C, patient given
Paracetamol (Biogesic) 500mg 1 tab every 4 hours,
still with note of abdominal pain specifically in the
epigastric area. No consult was done.
1 day PTA, patient still with intermittent fever,
documented at 39.2 C, there was also note of loss of
appetite, >10x episode of nonprojectile vomiting, of
clear phlegm. Patient denies presence of cough, cold,
or bleeding. Sought consult at Pal Medical at Nichols,
Pasay City, where the private practitioner considered
Dengue. CBC advised to be done.
Morning PTA, CBC done w/c reveals possible viral
etiology, patient afterwards was admitted.
UA dy/st/7.5/trace/-/1.015/many/0-2/rare/rare
DNS1 Ag IgG IgM
BT O Rh pos
PT13.2/13.6/1.04/94%
PTT 39.7/29.2
KTU (6)
333A
9/3/2015
6:36 PM
414668
ADRALES, Franz
Gabrielle
5/M/16.5kg
4/28/2010
LPC
Acute
Bronchitis
PPI
Principe
CBC: 4.71/0.38/126/5.8/0.64/0.01/0.23/0.12/285
CC:cough
6 days PTA, pt developed non-productive cough with
assoc. Fever (Tmax of 40.2). Paracetamol was given.
5 days PTA, consult was done. Dengue test done
Binos
333D
9/1/15
8:51AM
610134
D5 NM 1L x 55cc/hr
TURLA,
JimraldReuel
Mojica
6/M/22kg
10/20/2008
Manila / LPC
ATP Non
Exudative T/C
UTI
ATP;Systemic
Bacterial
Infection
PP
Balasbas
Carrillo
335
8/31/2015
5:14 PM
487400
Cabrera
ICASIANO, Nathan
2/M/11kg
Acute
Bronchitis T/C
Pneumonia
PPI
Baradi
Salbutamol 1 neb q 6
Paracetamol 250/5 2.5ml PRN
Cefuroxime 250 IV q6 D5 9/5 12NN
Ventolin expectorant 3 ml TID
7/26/2013
LPC
D5 IMB 500cc x 48-49cc/hr (FM+10) D5
IMB 500cc x 43-44c/hr (FM)
338
8/31/2015
2:00 PM
610109
Binos
339
9/3/2015
1:34 pm
604221
Carrillo
GARIN, Brayden
Marcus G.
1m5d/M/4.6kg
7/27/2015
LPC
MITTON,Patrick
Ezekiel
2 mos/M/6.2 kg
Partial Gut
Obstruction T/C
Hirschprung
Disease Vs.
Intussusception
Gut
o
Obstruction 2
to Incarcerated
Inguinal Hernia
with testicular
infarction, Right
S/P Inguinal
Exploration,
reduction of
incarcerated
small bowel,
Herniotomy,
Orchiectomy R
T/C UTI
PPI
Viola
Catangui
/Lunas
PP
Principe
7/02/2015
LPC
INALDO, Jaime
Inigo L.
2/M/19kg
11/01/2012
ATP NE with
mod sign of dhn
CC: Fever
2 days PTA, patient had intermittent fever TMax 39.0
accompanied with headache, body malaise. No other
associated symptoms like cough and colds.
Paracetamol was tajen 7ml Q6 which afforded
temporary relief.
1 day PTA, still with fever TMax 39.5 with above
mentioned symptoms. Patient noted vomiting PIF.
Paracetamol 7ml taken.
Persistence of above mentioned symptoms ptompted
ER consult. Hence this admission
CBC: 4.56/.36/117/8.4/.46/.04/.38/.12/547
CC: poor oral food intake, cough
6 days PTA, patient had fever (Tmax: 38 C)
associated with productive cough, 1 episode of
vomiting of previously ingested milk and decreased
appetite. No colds, DOB, LBM, rash noted. Patient
was given Paracetamol 250/5 which afforded
temporary fever relief. No consult was done.
5 days PTA, still with above symptoms.
4 days PTA, patient still with cough and decreased
appetite but no more fever. No meds given and no
consult was done.
Persistence of poor oral food intake prompted ER
consult and was subsequently admitted.
CBC: 3.5/0.34/113/9.7/0.28/0.03/0.56/0.13/495
5 days PTA, (+) vomiting nonbloody, nonbilous, (+)
phlegm, (+) colds
4 days PTA, consult done at LPMC. CXR done,
initially treated as Pneumonia. (-) BM.
3 days PTA, enlarging abdomen, (+) greenish mixed
with yellowish vomitus.
2 days PTA, abdxray and abdutz doneileus. (-) BM
1 day PTA, suppository inserted, small amount of BM
noted. OGT inserted.
Few hours PTA, due to card issues, opt to transfer
here due for pedia surgery service, hence admitted..
UA:ly/h/6.0/neg/neg/1-3/1-3/ec-few/b-few/mt-few
Typhidot IgM (-) IgG (-)
Dengue blot IgM (-) IgG (-)
341
9/2/2015
10:29 pm
467632
HCI
Custodio
CBC: 3.75/.31/107/6.2/.36/.01/.51/.12/280
UA: y/st/6.0/+1/neg/1.025/0-2/many/ec-rare/bmany
CC: Fever/Chills
2 days PTA, patient had intermittent undocumented
fever. No other associated symptoms like cough,
colds,d iarrhea , and vomiting noted. Patient given
with Paracetamol which afforded temporary relief.
1 day PTA, patient with intermittent fever
accompanied with colds. Paracetamol taken.
Few hours PTA, patient still with fever experienced
chills and noted to have cyanotic lips which prompted
ER consult.
At the ER, patients temperature was 39.0. No other
associated symptoms noted. Hence this admission.
CBC 9/2 5.0/.40/134/8.1/.80/.02/.07/.11/178
CC:
Morning prior to admission, patient started to
experience intermittent fever, with Tmax 38.4 C.
UA9/3: y/h/6.5/-/-/1.020/0-1/0-2/occ/few
Bonzo
LPC
PPI
Principe
D5 NM 1L x KVO
MGH
355
9/2/2015
11:05 pm
366024
Bonzo
ERICTA, Marietta
Eliz D.
7/F/21kg
BAIAE T/C
PCAP
PPI
Fuentes
06/28/2008
LPC
PD
356
8/29/15
1.24am
609930
Cabrera
MELGAR, Zion
Asher
8mo/M/9.7kg
Staph Scalded
Skin
Syndrome
PPI
Principe
12/2/14
Muntinlupa/LPC
MGH
357
9/4/15
8:46pm
584101
Carrillo
VIRAY, Micah
Ingrid O.
6/F/29kg
JRA; PCAP
PPI
Bueno
12/09/2008
Paranaque
DTR
Acute
Bronchitis
PPI
Viola
CC: vomiting
2 days PTA, patient started to have productive cough,
and colds. No fever noted. No meds given, no consult
was done.
Morning PTA, still with above symptoms noted fever
of 38.7. Patient given Calpol, and Asmalin, with noted
relief of symptoms.
Few hrs PTA, patient had 2 episodes of vomiting
watery material with phlegm, hence ER consult and
subsequent admission.
CBC: 4.61/.37/127/9.9/.52/.04/.35/.09/274
UA: dy/h/6.0/-/-/1.020/0-2/5-7/b-rare/mt-mod
ESR: 8 (0-20)
CRP: 6mg/ml (0-10)
ASO: Negative
Creatinine: 69
BUN- 3.2
C3:
UA:
CXR (9/5):
UA ly/h/6.0/neg/neg/1.020/0-2/2-4/rare/rare
CXR APL (o): NCATS
216
9/1/15
2:38PM
439503
CANALES, Art
Christian
Evangelista
7/M/18kg
Bonzo
12/05/2007
Muntinlupa/LPC
DFS PCAP
moderate risk;
Anemia prob
sec to
hemolysis
infection vs
blood loss vs
IDA
PPI
Policar
Arca
DISCHARGES (5)
302A
CAEZA, John Eris
9/1/15
F.
1:02PM
7/M/31.5kg
343497
Carrillo
306
8/29/15
6:45pm
609994
05/19/2008
Cavite
Carrillo
Gen. Urticaria;
Multiple
Lesions
Hypersensitivity
reaction (Gen.
Urticarira) sec
to bacterial
infection
Acute
Bronchitis with
some
dehydration
Acute
Bronchitis
PPI
Anchores
Hydrocortisone 135mg IV q6
Diphenhydramine 25mg IM (single dose)
Mupirocin ointment TID
Cetirizine (Alnix) 5ml BID
Cetaphil lotion TID
D5 NM IL x 63 cc/hr
PPI
Anchores
327B
9/1/15
11:40am
490094
CALAHATI, Paulyn
Nicole Sedaria
9/F/45kg
12/23/2005
Batangas
DFS DHF II
PP
Alcala/
Tugade
UA: ly/h/6.5/neg/neg/1.010/0-2/1-3/ec-occ/b-occ
NS1Ag: (-)
IgM: (-)
IgG: (-)
CXR (o) Interstitial Pneumonitis
PT: 13.2/12.0/88/126%
PTT: C- 32.7/ T-29.2
Peripheral Blood Smear: Normochromic, slightly
microcytic rbc with mild anisopoikilocytosis.
Platelets and wbc appear adequate in number with
slight predominance of lymphocytes. Few reactive
lymphpcytes seen. Few baskets cells are also
present. No primitivity noted.
Retics___________________________________
UA______________________________________
CXR_____________________________________
UA: ly/h/6.5/tr/neg/1.015/1-2/4-8/ec-few/b-few
UA:dy/h/6.0/tr/-/1.025/3-4/4-8/occ
SE:yb/m/-gb/pc-2-4/m+/EHCseen/rbc1-2
ChesXray (o): Normal
CC: Fever
9 days PTA, patient had non productive cough.
Broncaire expectorant was given but no relief.
7 days PTA, patient still with on-off non productive
cough accompanied with colds.
3 days PTA, patient had fever T 39.9. Paracetamol
(Tempra) 5ml but only had slight decrease in
temperature.
2 days PTA, patient still with fever T 37.8. Sought
consult and was given Amoxiclav 5ml BID,
Salbutamol TID, andAllerkid 5ml OD.
3 hours PTA, patient still with fever T 40C.
Paracetamol given. Persistence of fever prompted
consult. Hence this admission.
CBC 9/1 am: 5.20/.43/141/6.5/.70/.01/.17/.12/172
CBC 9/1: 4.70/.39/129/5.2/.43/.01/.52/.04/136
CBC 9/2 6am 4.66/.39/129/4.3/.40/.02/.48/.10/132
CBC 9/2 6pm 5.12/.43/140/5.5/.39/.02/.47/.12/124
CBC 9/3 6am 4.69/.39/130/5.7/.48/.03/.37/.12/144
CBC 9/4 6am 4.69/.39/129/6.0/.48/.05/.36/.11/171
Bonzo
D5 LR 1L x 135cc/hr113 cc/hr
5 days PTA, patient started to have fever tmax 40C
with associated productive cough with whitish
sputum, colds, and decrease in appetite. No note of
vomiting or difficulty of breathing. Patient given
Paracetamol 250mg/5ml 10ml which afforded
temporary relief. No consult done.
4days PTA, above symptoms persisted. No consult
done.
3 days PTA, upon waking up noted no fever. Fever
recurred night that day. Paracetamol continued.
2 days PTA, above symptoms persisted. No consult
done.
1 day PTA, at morning, sought consult due to fever
persistence. At night, there was an episode of
epistaxis, L nasal cavity which lasted for <10mins.
Patient was brought to the ER and eventually sent
home improved. Patient also complained of
357
8/31/2015
8:08 pm
414406
Pneumonia
Pneumonia
Moderate Risk
PPI
Principe
12/06/2010
LPC
Binos
CASTANEDA,
JosaiahSedwick S.
7/M/24kg
07/18/2008
LPC
AGE with
moderate
dehydration r/o
intestinal
amoebiasis
AGE with mod
dhn
PP
Suratos
Teves/
Bumanlag
UA y/h/6.0/neg/+3/1.025/0-2/2-3/rare/few
FA y/w/-/1-2/-/none seen/0-2 hpf/fat globules seen
Na 133 dec
K 3.1 dec
Cl 100 N