UNIVERSITY OF SANTO TOMAS HOSPITAL

Espana Blvd., Manila 1008

Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
No. 0013163
Medical Abstract
Last Name Birthday Age Sex Admission Date Discharge Date
VALENCIA 12/04/1957 50 ☐ MALE 12/26/2017 10/19/17
 FEMALE
First Name X Single Philhealth No. Admission No. Hospital No.
MARITES Married 17L00345 17-220000095752
Middle Name Widow Senior Citizen No. Room/Bed No. Ward
IGLESIA 200F ESPANA
Patient Contact No.
Primary Diagnosis: 09185681467
ASHD, CAD, NSTEMI, not in failure class IIIC
Final Diagnosis

Secondary Diagnosis

Date of Operation
Surgeon(s)
Anesthesiologist(s)
Attending Physician (s) Dr. Tapispisan
Condition on
[X] Improved □ Not Improved [X] Stable □ DAMA/HAMA □ Expired
Discharge
Admitting History
Chief Complaint Physical Exam on Admission
For chemotherapy General: Conscious, coherent, not in cardiorespiratory distress, oriented to 3 spheres
History of Present Illness BP: 150/90 PR: 82 bpm RR: 17 cpm O2 98% Temp: 36.2°C Wt: __ kg Ht: 172.7 cm
1 month PTA, patient would experience chest pain described as “mabigat” graded 7/10 that would radiate to Skin: warm, not dry, no pallor, no jaundice
the back and last for 30 seconds which would be relieved by rest. No headache, dizziness, nausea, vomiting Head: no facial asymmetry
and dyspnea were noted. No medications were taken. No consult was done. Eyes: pink palpebral conjunctiva, anicteric sclera, isocoric pupils 2-3 mm ERTL
Ear: normal set ears, no aural discharge, no tragal tenderness
Interval history showed frequency of chest pain that would still radiate to the back and increase in severity. Nose: nasal septum midline, no nasal discharge, non-congested turbinates
Still no headache, dizziness, nausea, vomiting and dyspnea were noted. No medications were taken. No Throat: non-hyperemic, no enlarged tonsils
consult was done. Mouth: moist lips and buccal mucosa, no oral ulcers, non-hyperemic posterior pharyngeal wall, tonsils
not enlarged
17 hrs PTA, patient experienced chest pain while cleaning which he described as “nadaganan” graded 10/10 Neck: no palpable cervical lymphadenopathies, no appreciable thyroid enlargement, trachea midline,
that would radiate to the back and was not relieved by rest. Patient then consulted at the ER in Medical neck veins not distended
Center-Valenzuela where Troponin I was done and resulted to be elevated 3.69 ng/mL. The patient was given Repiratory: symmetrical chest expansion, equal vocal and tactile fremiti, resonant on all lung fields,
Isosorbide dinitrate 5mg sublingual, 4 tablets of aspirin, 4 tablets of clopidogrel and Tramadol IV. The normal breath sounds
physician in Medical Center-Valenzuela advised to consult a tertiary hospital that would better accommodate Cardiovascular: adynamic precordium, no heaves/thrills/lifts, rhythm regular, apex beat at 6th LICS AAL,
the patient’s treatment hence admission. loud s1 followed by soft s2 at the apex, soft s1 followed by loud s2 at the base, no murmurs
Gastrointestinal: flat, flabby, normoactive bowel sounds, tympanitic on percussion, no direct or
rebound tenderness on all quadrants.
Genitourinary: (-) CVA tenderness
Extremities: (-) bipedal edema, (-) deformities, (-) cyanosis, pulses full & equal

Neurological Exam:
GCS 15 (E4V5M6)
CNI: no anosmia
CN II: 3-4 mm pupils ERTL, direct and consensual reflex intact
CN III, IV, VI: full and intact EOM
CN V: intact V1-3
CN VII: can frown, smile, puff, clench teeth, raise eyebrows, close eyes tightly; no facial asymmetry
CN VIII: no gross hearing impairment
CN IX, X: uvula midline
CN XI: can turn head and shrug shoulders against resistance
CN XII: tongue midline on protrusion
Motor: MMT 5/5 on all extremities
Cerebellum: No dysmetria, no dysdiadochokinesia
Sensory: no sensory deficit
Reflexes: ++ DTR on upper extremities, lower extremities were not assessed due to patient’s discomfort
Pathologic reflexes: (-) babinski
Meningeal: (-) nuchal rigidity, (-) Kernig’s sign, (-) Brudzinski

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Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph

Past Medical History Family History List of Current Medications

(-) HTN (+) MI – father and brother None
(-) DM (-) stroke
(+) PTB – completed 6 months of treatment (2005) (-) DM Alert – Allergic to
(+) Cancer – Lung Cancer- brother None
(-) CA
(-) Thyroid disorders
(-) Asthma
(-) Arthritis
Previous Hospitalization: 2011 – Motor Vehicle Accident
No known allergy

Personal and Social History

Previous smoker – 44 pack-years

Occassional Alcoholic beverage drinker
Denies illicit drug use

Admitting Diagnosis:
Pancreatic adenocarcinoma
Prepared by: Signature over printed name Designation Date

GALOPE/GATCHALIAN/GLORIA Clinical Clerks-in-Charge 12/26/17

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 UNIVERSITY OF SANTO TOMAS HOSPITAL
Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
Clinical Discharge Summary
Problems Action / Intervention
Upon admission (12/26/17), patient stable, ambulatory, conscious, coherent, not in cardiorespiratory distress. Patient was hooked to IVF PNSS at 40cc/hr. Patient is for day 1
chemotherapy (FORFIRINOX), which was started at BCI-ATV, ongoing 5FU 930mg in PNSS 1L to run for22hours as side drip to mainline IVF. Patient was given metoclorpomide
10mg/IV for nausea/vomiting every 6 hours as needed. Patient was advised to limit visitors, practice strict hand washing, wear mask at all times and avoid direct exposure to cold
wind, aircon, cold drinks and cold food. Patient’s diet was altered to 30kcal/kg/day, 60% CHO, 25% fats, 15% CHON, divided into 3 meals and 2 snacks, full neutropenic diet. No
fresh fruits, vegetables or raw meat.

The rest of the hospital stay was unremarkable.

Physical Exam on Discharge
Physical Examination Neurological Exam:
General: Alert, awake, follows commands, oriented to person, place and time,
General: conscious, coherent, not in cardiorespiratory distress able to name and repeat
Vital Signs: BP 130/100 CR 135 bpm, RR 28 cpm, Temp. 37.0 °C, O2 Sat 98% room air Conscious, coherent, cooperative, oriented to person, place and time; GCS 15
Anthropometrics: Ht. 5’2 cm, Wt. 109 lbs BMI 19.93 kg/m2 (E4V5M6).
Skin: warm, dry skin, no active dermatoses, multiple hyperpigmented ill-defined patches on Cranial Nerves:
both lower extremities and scalp CN I – not assessed
Head: (-) moon facies, no deformities, evenly distributed hair CN II – primary gaze midline, pupils isocoric, 3-4mm ERTL
Eyes: Pupils 2-3 mm ERTL, eyelashes not matted, pink palpebral conjunctivae, anicteric sclera CN III, IV, VI – EOMs full and intact
Ears: no deformities, no aural discharge, no tragal tenderness CN V – intact sensory and motor, can clench jaw
Nose: nasal septum midline, no nasal discharge, pink nasal mucosa, turbinates not congested CN VII – can smile, can frown, can pout lips, close eyes; shallow left nasolabial
Mouth: moist lips and buccal mucosa, no oral ulcers, tonsils not enlarged, posterior fold
pharyngeal wall non-hyperemic, tongue midline CN VIII – gross hearing intact
Neck: (-) nuchal rigidity, no palpable cervical lymphadenopathy, thyroid gland not enlarged, CN IX, X – uvula midline
no bruits CN XI – can shrug shoulders against resistance, can move neck side to side
Lungs: no scars, no deformities, symmetrical chest expansion, clear breath sounds on both against resistance
lung fields, resonant on all lung fields, equal vocal and tactile fremiti CN XII – tongue midline
Heart: adynamic precordium, AB at the 5th ICS, no lifts, heaves, no thrills, (-) murmurs, S1
louder than S2 at apex, S2 louder than S1 at base Motor: LUE:4/5 RUE:5/5 LLE: 3/5 RLE: 5/5
Gastrointestinal: Globular, soft, non-tender abdomen on light and deep palpation,
normoactive bowel sounds, tympanitic on all quadrants Neck flexion and extension 5/5
Genitourinary: (-) CVA tenderness Right Left
Extremities: no gross deformities, (-) pedal edema, pulses full and equal on all extremities Shoulder abduction and
adduction 5/5 4/5

Elbow flexion and 5/5 4/5

extension
Finger abduction and 5/5 5/5
adduction
Hip flexion 5/5 5/5
Hip extension 5/5 5/5
Knee flexion 5/5 3/5
Knee extension 5/5 3/5

Cerebellum: (-) dysmetria, (-) dysdiadochokinesia (-) dysarthria

Sensory: No sensory deficit
Deep Tendon Reflexes: ++ on all extremities
Meningeal: (-) nuchal rigidity, (-) Brudzinski sign, (-) Kernig sign

Imaging Pertinent Laboratory Results Operative Findings

N/A See attached LFS N/A
Histopathologic Diagnosis

N/A

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Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph

Discharge Medication Sheet

Birthdate Gender Admission Date:
Last Name VALENCIA 12/04/1967 Female 12/26/2017

Patient Age Discharge Date:

Name
First Name MARITES 50 10/19/17

Discharge Diagnosis:
Middle Name IGLESIA ASHD, CAD, heart failure, reduced ejection fraction not in failure, class IIIC; COPD suspect; DM type II

Medications:
Brand (Generic Name) Dose Frequency Duration/ End Date of Intake
(Pangalan ng Gamot) (Dosis) (Dalas ng Pag-inom) (BIlang ng araw at huling petsa ng pag-inom ng gamot)
Atorvastatin 40 mg/tab 1 tab once a day before bedtime

Trimetazidine 35 mg/tab 1 tab once a day

ISMN 30 mg/tab 1 tab once a day

Amlodipine 19 mg/tab 1 tab once a day

Carvedilol 25 mg/tab 1 tab twice a day

Digoxin 0.5 mg/tab ½ tab every 48 hours

Omeprazole 40 mg/cap 1 cap once a day 30 minutes before breakfast

Lactulose 30 cc Once a day before bedtime (hold if bowel movement

is 2-3x/day)
Sitagliptin 50 mg/tab ½ tab at bedtime

Special Instructions/Alerts:

Accomplished by: Approved by:

GALOPE/GATCHALIAN/GLORIA DR. SIOSON/JOVELLANOS

Signature over Printed Name Signature over Printed Name

Designation: Clinical Clerks-in-Charge License No.: PTR No.:

Discharge Instruction
Acknowledged by: __________________________________________________
Patient/ Patient Representative (Signature over Printed Name)

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Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph

Follow-up Record
Last Name Birthdate Age Gender
VALENCIA
12/04/1967 50 Female
Patient First Name
MARITES
Name
Middle Name
IGLESIA
Ward Room/ Bed No. Admission No. Hospital No. Admission Date Discharge Date
ESPANYA 200F 17L00345 17-220000095752 12/26/2017 10/19/17
FINAL DIAGNOSIS
Date of Operation Operation/s Done Anesthesia Technique Rendered

Patient’s CONDITION
[X] Improved □ Not Improved [X] Stable □ DAMA/HAMA □ Expired
At time of DISCHARGE
Vital Signs State Reason for DAMA/ HAMA Primary Cause of Death

Mark X on the box BP 110/70

N/A N/A
HR 56

RR 18

Temp 36.4

Pain Score 0/10

Any important precautions: (wound care/ diet/ what to avoid/ activities allowed for patient)

PLEASE seek medical care, if the following SIGNS/SYMPTOMS are present: Bleeding, Urinary retention, pain

If URGENT CARE is needed

FOLLOW-UP on:
CALL this Telephone No.:

Where to go for follow-up: MARK with X CALL this Person:

☐OPD – Dermatology Prepared by:

☐OPD – ENT
☐OPD – Family Medicine
XOPD – Internal Medicine Name
☐OPD – Neurology GALOPE/GATCHALIAN/GLORIA
☐OPD – OB-Gyne Signature over Printed Name
☐OPD – Ophthalmology Designation Clinical Clerks-in-Charge
☐OPD – Pediatrics
☐OPD – Rehab Med Certified correct by:
☐OPD – Surgery
☐OPD – Anesthesiology
☐OPD – Doctor’s Clinic: Room No. ________ Name
DR. SIOSON/JOVELLANOS
Signature over Printed Name
DISCHARGED DOCUMENTS to be complete
Designation
☐Discharge Medication Sheet ☐Hospital PSS Resident-in-Charge
☐Follow-up Record ☐Discharge Slip

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