Consults

May 6, 2014
CONSULTS
1. Ricardo
Abarquez, 68/M
Patient came in for follow-up check-up, (-) dysuria (-)abdominal pain
(-) increased urinary frequency (-) fever, (+) 1 episode of hemoptysis
1 month PTC, (-) dyspnea, (-) tachypnea, (-) cough, no other
subjective complaints
General Survey: alert, cooperative not in respiratory distress
VS:
BP= 150/90 mmHg
RR= 19 CPM
PR= 80 bpm
Temp= 36.5 C
BMI= 21 kg/m
2

Skin: warm to touch, senile turgor
HEENT: anicteric sclerae, pink palpebral conjunctiva, (-)
lymphadenopathies
C/L: (-) retractions, clear breath sounds, equal chest expansion
CVS: distinct heart sounds, no murmurs
Abdomen: flabby, normoactive bowel sounds, soft, (-)
tenderness
GUT: (-) KPS
Ext: strong peripheral pulses, (-) edema, CRT <2 secs

Assessment:
1.UTI, resolving
2. Essential Hypertension stage II

For CXR PA
Repeat UA
Metoprolol
50mg/tab OD in AM
Amlodipine 5 mg/tab
OD after supper
Multivitamins 1 tab
OD
Follow-up on Friday
10 am with results

2. Bernard Suello,
59/M
3 months PTC, onset of exertional dyspnea upon climbing stairs (10
steps) associated with chest tightness, (+) 2-pillow orthopnea, (+)
hoarseness, (+) occasional dysphagia,(-) chest pain, (-) body malaise.
Known chronic smoker, 40 pack years, stopped smoking in 2012.

O= alert, cooperative, not in respiratory distress
VS:
BP= 120/80 mmHg
RR= 20 cpm
PR=90 bpm
Temp.= 36.5 C
Skin= (-) jaundice,warm to touch, good turgor
HEENT: anicteric sclerae, pink palpebral conjunctiva,(+) neck
vein engorgement, left and right, no visible mass, trachea in
midline, no palpable masses, no lymphadenopathies
C/L: clear breath sounds, equal chest expansion
organomegaly, (-) tenderness
GUT: (-) KPS
Ext: strong peripheral pulses, CRT <2 secs, (-) edema

Labs:
CXR PA (4/18/2014 VSMMC)
Fibrosis, RUL
Atherosclerosis of Thoracic Aorta
Pleural Thickening, right

Assessment:
T/C COPD
For ECG 12L, neck
UTZ, CBC, serum
Creatinine
Carbocisteine
(Mucoflem) 1 tab
TID
Omeprazole 40
mg/tab a tab OD for
7 days
TCB on 5/9/2014
Friday with results

3. Emma Suello,
59/F
Wt: 26 kg
Five days PTC, patient had onset of a productive cough associated
with scanty sputum. There was no fever or anorexia. No
medications taken.
Three days PTC, patient complained of difficulty going to sleep at
night. Cough still persisted. Patient complained of muscle weakness
and dyspnea when walking a few steps.

Not a known diabetic, hypertensive or asthmatic. No known FDAs.
No previous hospitalizations.

Non-smoker, non-alcoholic. Fond of drinking instant coffee, 4 10
cups in a day. Usual diet: fried food. Currently works as a household
help.

Menarche at 13 years, with regular monthly cycles. Menopausal at
age 36. OB Score G1P1(1001). Sexual history unremarkable. No pap
smear done.

ROS: (+) 3-pillow orthopnea since 4 months PTC, no chest pain

General Survey: alert, awake, afebrile, in mild respiratory distress
BP 110/80 mmHg
PR 104 bpm
RR 23 cpm
T 36.5 C
Skin: no lesions, warm, good turgor
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no alar
flaring, moist lips and oral mucosa
C/L: no retractions, equal chest expansion, fine crackles both lung
bases
CVS: AP, DHS, no murmurs, tachycardic at 110 bpm
Abdomen: flat, soft, non-tender
GUT: (-) KPS, bilaterally
Extremities: no edema, strong peripheral pulses, CRT < 2 sec
CNS: within normal limits

Assessment:
Community Acquired Pneumonia Moderate Risk
Reduce caffeine
intake to 1 cup/day
Medications:
Ferrous Sulfate 1 cap
OD daily
Cetirizine 10 mg/tab
1 tab OD qhs
Amoxicillin 500
mg/tab 1 tab TID for
7 days
Carbocisteine 500
mg/cap 1 cap TID for
7 days
Labs:
CXR-PA
CBC
Urinalysis
Serum creatinine
ECG-12L
TCB May 9, 2014
4. John Carlo
Resojento, 1 yr 5
mo/M
5 days productive cough, and coryza with intermittent
undocumented fever, given Paracetamol 100mg/ml, 1 ml with
temporary relief. (+) slight loss of appetite, (-) vomiting, (-)loose
stools

O> slightly irritable but consolable
RR: 60s HR:95 Temp:37.1 wt: 9kg
Skin: warm, good turgor and mobility, (-)cyanosis
HEENT: anicteric sclerae, moist lips and tongue, slightly sunken
anterior fontanel
C/L: (-) retractions, equal chest expansion, (+) harsh breath sound
on right lung field
CVS: Distinct heart sounds, no murmurs
Abdomen: NABS, soft, nontender
Extremities: warm, strong pulses, CRT <2secs

Assessment:
Pediatric Community Acquired Pneumonia C
Paracetamol
100mg/ml, 1 ml (AD
11.11) PRN for temp
37.5C
Amoxicillin
125mg/5ml, 6ml TID
(AD 50) x 7 days
Carbocisteine
250mg/5ml, 1.5ml
TID (AD 25) x 7 days
Cetirizine 2.5mg/ml,
0.9ml OD (AD .25)
Multivitamins 1 ml
OD
Increase oral fluid
intake
Follow up on May 9,
2014

5. Mary Jane S: 1 week PTC, patient noted pruritic skin lesions at both hands and Cetirizine 10 mg tab
Gabytero, 10/F
Wt: 20 kg
HR- 80
RR- 19
T- 36.8

feet. (-) fever,
(-) Nausea and vomiting, (-) LBM, (+) Coryza noted. Condition
persisted which prompted consult.

O: skin- (+) multiple papular lesions on both hands and feet
HEENT- Anicteric sclera, Pink palpebral conjunctivae
C/L- Clear breath sounds
CVS- distinct heart sounds
Abd- NABS
Ext- strong pulses

Assessment:
Scabies
once daily
Permethrin 5%
lotion: apply evenly
from neck to toe at
bedtime
6. Dhea Zyrielle
Anne Genandoy,
6mo/F
Wt: 6 kg
HR- 110
RR- 45
T- 36.8

S: 3 days PTC, patient noted onset of coryza with occasional
productive cough with whitish sputum.
A day PTC, sputum was noted to be yellowish. (-) fever, (-) Nausea
and vomiting, (-) LBM noted. Condition thus prompted consult.

O: skin- warm, good skin turgor
Abd- NABS
Ext- strong pulses
Assessment:
URTI
Multivitamins
(Ceelin) 0.6 ml once
daily
Encourage
breastfeeding

May 9, 2014
CONSULTS
1. Ricardo
Abarquez, 68/M
Patient came in for follow-up check-up (-) dysuria (-) cough (-)
hemoptysis (-) fever (-) abdominal pain, no subjective complaints

O= alert, cooperative not in respiratory distress
VS:
BP= 130/80 mmHg
RR= 20 CPM
PR= 80 bpm
Temp= 36.5 C
Skin: warm to touch, senile turgor
HEENT: anicteric sclerae, pink palpebral conjunctiva, (-)
lymphadenopathies
C/L: (-) retractions, (+) rales on both lower lung fields, equal
chest expansion
tenderness
GUT: (-) KPS
Ext: strong peripheral pulses, (-) edema, CRT <2 secs
Labs:
Urinalysis (5/7/14 JS med)

Ciprofloxacin 500
mg/tab BID 7 days
Carbocisteine
500mg/cap BID 5
days
Continue Metoprolol
50 mg tab OD in am
and Amlodipine 5mg
tab OD after supper
Multivitamins 1 tab
OD
Increase Oral Fluids
To come back on
5/19/14 Monday for
follow-up and BP
monitoring

CXR PA
Round Pneumonia Left midlung

Assessment:
1. Recurrent UTI
2. CAP
3. Essential Hypertension Stage II
2. Bernard Suello,
59/M
Patient came in for follow-up with the following lab results:
CBC (5/6/2014 Hi-Precision)
WBC= 6.7
RBC= 4.68
Hemoglobin= 132
Hematocrit= 0.39
MCV= 84 fL
MCH= 28 pg
MCHC= 0.34
Differential Count
Segmenters= 67.5 %
Lymphocytes= 21.4 %
Monocytes= 5.3 %
Eosinophils= 5.2 %
Basophils=0.6 %
Serum Creatinine= 1.02 mg/dL

For Neck UTZ
TCB on May 13, 2014
Continue
medications
3. Emma Suello,
59/F
Patient came in for follow-up with lab results:
Chest PA (5/6/14)
Chronic inflammatory process, both lungs, moderate cardiac
enlargement (CT ratio: 0.55)
ECG-12L (5/6/14)
Sinus rhythm with short PR, possible left atrial enlargement.
Rightward axis.
T-wave abnormality, consider anterior ischemia.
Patient was not able to tolerate Amoxicillin. There was slight
improvement of sleeping patterns.

Assessment:
CAP-MR vs. PTB, Category 5
Additional labs:
AFB Sputum Smear
Azithromycin 500
mg/tab 1 tab OD for
7 days
TCB with results of
previously requested
labs
4. Darren 2 days nonproductive cough and coryza with clear discharge (- Multivitamins 5ml
Arrenchado, 6/F )febrile episodes, (-)vomiting, (-)anorexia, no medications taken
O> alert, NIRD
RR: 20 HR: 75 temp: 36.8 Wt. 18kg
Skin: warm, good turgor and mobility
HEENT: anicteric sclerae, pink palpebral conjunctivae
C/L: equal chest expansion, clear breath sounds
Abdomen: Flat, NABS, soft, nontender
Extremities: strong peripheral pulses, CRT<2secs
Assessment:
Upper Respiratory Tract Infection

OD
Increase oral fluid
intake

5. Arlene Caballero,
10/F
3 days productive cough with greenish phlegm, (+) coryza, (-) febrile
episode, good appetite, no vomiting, no medications taken
O> alert, NIRD
RR: 20
HR: 75
Temp: 36.6
Weight: 25kgs

C/L: equal chest expansion, clear breath sounds

Assessment:
Carbocisteine
250mg/5ml, 3.5ml
TID (AD 21) x7days
Multivitamins 5ml
OD
Increase oral fluid
intake

6. Jelly Caballero,
52/F
6 days productive cough with greenish phlegm, (+) malaise, (-)
febrile episodes, (-)dyspnea, no anorexia
non-diabetic, non-hypertensive, non-asthmatic
O: alert, NIRD
RR: 19
BP: 130/80mmHg
HR: 76
afebrile
C/L: equal chest expansion, (+)wheeze RLF

Assessment:
Acute Bronchitis
Amoxicillin
500mg/cap, 1 cap
BID
Carbocisteine
500mg/cap, 1 cap
TID
Increase oral fluid
intake

7. Heart Jade
Jacalan, 2/F
Ht: 85 cm
Wt: 11.5 kg
5 days PTC, onset of coryza associated with clear, watery secretions
and a non-productive cough. No fever, anorexia, dyspnea, or
abdominal pain. No changes in bladder and bowel habits. Mother
however noticed patient to have fast breathing when patient is
asleep. Not a known asthmatic, no known FDAs.
General Survey: examined alert, awake, afebrile NIRD
RR: 26 cpm
HR: 96 bpm
T: 35.6 C
Skin: with multiple, papular lesions at the back and chest area,
warm, good turgor and mobility
HEENT: anicteric sclerae, pink palpebral conjunctivae, no
Amoxicillin 250/5 3.5
mL TID for 7 days
(AD: 55.26 mkD)
Carbocisteine 250/5
1.5 mL TID for 7 days
MV (Diavit) 5 mL OD
daily
Increase oral fluids
Hypoallergenic soap
for bathing
TCB Tuesday, May
13, 2014
conjunctival suffusion, no alar flaring, moist tongue, no oral lesions
C/L: equal chest expansion, no retractions, harsh breath sounds on
both lung fields, no wheezes
CVS: adynamic precordium, distinct heart sounds, normal rate with
regular rhythm, no murmurs
Abdomen: protuberant, soft, non-tender

Assessment:
Pediatric Community Acquired Pneumonia - A
8. Aris Kezaga, 6/M 4 days PTC, patient had onset of productive cough with whitish
sputum. No associated symptoms such as fever, coryza, rashes,
body malaise or loss of appetite.
Persistence of condition prompted consult.
O> Examined an awake, active, afebrile, not in respiratory distress
patient with the ff V/S:
Wt. 13 kg
HR= 100bpm
RR= 28cpm
Temp= 37.1C
Skin: no lesions, warm, good turgor and mobility
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no naso-
aural discharges, no tonsillopharyngeal congestion
C/L: equal chest expansion, resonant, clear breath sounds, no rales,
no wheeze
CVS: distict s1 and s2, normal rate and rhythm, no murmurs
Abdomen: globular, normoactive bowel sounds, tympanitic, soft,
nontender
Ext: CRT<2 secs, strong peripheral pulses
Assessment:
Vitamin C syrup 1
tsp OD
Encourage oral fluids
Follow-up check-up
after 3 days

9. Irene Rezaga,
43/F
S> 1 week PTC, patient had onset of productive cough with
yellowish sputum associated with minimal coryza. No other
associated symptoms such as fever, dyspnea, changes in bowel or
bladder habits.
Persistence of cough prompted consult.
O> Examined an awake, alert, responsive, coherent, afebrile, not in
respiratory distress patient with the ff V/S:
Wt. 46 kg
HR= 88bpm
RR= 22cpm
Temp= 36.6C
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no naso-
aural discharges, no tonsillopharyngeal congestion
C/L: equal chest expansion, resonant, clear breath sounds, no rales,
no wheeze
CVS: distict s1 and s2, normal rate and rhythm, no murmurs
Abdomen: globular, normoactive bowel sounds, tympanitic, soft,
nontender
Ext: CRT<2 secs, strong peripheral pulses

Assessment:
Carbocisteine
(Solmux) 1 cap TID
for 5 days
Vitamin C
500mg/tab 1 tab OD
Encourage oral fluids
Follow-up check-up
after 3 days

10. Athena Sofie S: 3 days PTC, patient noted onset of non-productive cough. (-) Multivitamins
Amihan, 1/F
wt- 10 kg
HR- 110
RR- 48
T- 36.9

fever, (-) Nausea and vomiting,
(-) LBM noted. Condition persisted which prompted consult.
Abd- NABS
Ext- strong pulses

Assessment:
URTI
(Ceelin) 1.5 ml once
daily
Increase fluid intake

11. Sharifa Mae
Polistico, 7yo/F
wt- 14 kg
HR-80
RR- 19
T- 36.7

S: 1 week PTC, patient noted onset of productive cough with whitish
sputum which persisted and
turned greenish. (-) fever, (-) Nausea and vomiting, (-) LBM noted.
Condition thus prompted consult.
Abd- NABS
Ext- strong pulses

Assessment:
URTI
Amoxicillin
Trihydrate
250mg/5ml: 5 ml 3x
a day for 7 days (AD:
53.5)
May 13, 2014
CONSULTS
1. Chanica
Gatchalian, 4/F

Wt: 15 kg
HR: 132 bpm
RR: 23 cpm
T: 36.2 C
Six days PTC, patient had onset of fine, erythematous, pruritic,
papular rashes in the nasal and gluteal area. There was no fever,
coryza, or redness and eye pain noted. Lesions were noted to
gradually spread all over the body and later on evolved into
confluent patchesm crusts and secondary erosions. No medications
were given. No known food and drug allergies. No pets at home.
Elder sibling was noted to have the same lesions but were localized
in the dorsum of left hand.
Skin: (+) erythematous patches and plaques, crusts and erosions
generalized but more predominant in the nasal and gluteal area
HEENT: anicteric sclerae, no conjunctival injection, no oral lesions,
no tonsillopharyngeal erythema or congestion, moist tongue and
lips
Neck: supple, no LAD
C/L: ECE, CBS
CVS: AP, DHS, no murmurs
Abdomen: globular, soft, non-tender
Extm: no edema, srong pulses, CRT < 2sec

Assessment:
Impetigo
Cephalexin 250/5
syrup 4 mL TID for 7
days (AD: 40 mkD)
Mupirocin ointment
apply to lesions TID
for 7 days
Cetirizine 5/5 syrup
4 mL OD qhs (AD:
0.27 mkD)
Use hypoallergenic
soap
Improve hygiene
May 16, 2014
NO CONSULTS
May 20, 2014
CONSULTS
1. Emma Suello,
59/F

Wt: 29 kg
BP: 120/70 mm/Hg
HR: 84 bpm
Patient came in for follow-up with result of AFB Smear, 1
st
specimen
(5/18/14):

Few pus cells
Moderate epithelial cells
No acid fast bacilli
Ambroxol HCl 30
mg/tab 1 tab TID for
7 days
Salbutamol 2 mg/tab
1 tab TID for 7 days
Trimetazidine (
RR: 31 cpm
T: 35.8 C

CBC (5/18/14)
WBC 10.0
Neu 76.7
Lym 13.9
Mon 8.4
Eos 0.8
Bas 0.2
RBC 6.03
Hgb 15.9
HCT 49%
MCV 81 fL
MCH 26 pg
RDW 14.6
PLT 373k

Patient has completed course of Azithromycin. Still with productive
cough associated with whitish, non-blood streaked sputum. Still
with dyspnea on exertion, when walking 3 steps. Still complains of
distal muscle weakness. Appetite is good. No fever. Reports
improvement of sleeping patterns. No complaints of chest pain.

General Survey: alert, awake, afebrile, in mild respiratory distress
HEENT: anicteric sclerae, pink palpebral conjunctivae, no oral
lesions, no tonsillopharyngeal erythema or congestion, moist
tongue and lips
Neck: supple, no LAD, no neck vein engorgement, (+) use of
accessory muscles of the neck
C/L: ECE, no retractions, (+) rales R mid and lower lung lobes and L
lower lung lobe, (+) minimal wheezes right upper lung field
Extm: minimal Grade 1 pitting edema, strong pulses, CRT < 2sec

Assessment:
CAP MR vs. PTB, Category V
Vastarel MR) 35
mg/tab 1 tab BID as
maintetance
Additional labs:
Serum Creatinine
Serum K
Add one banana per
meal
For possible referral
to pulmonologist
and cardiologist
2. Franz Arthur Amihan 1yo/M
Mango ave., C.C.
wt.- 12 kg, HR- 130, RR- 35, Temp- 36.7
S: 1 day PTC, noted non-productive cough and 2 episodes of Loose bowel movement, non-bloody,
and non-mucoid, (-) fever, (-) vomiting. Condition prompted consult.
O: Awake, NIRD
C/L- clear breath sounds
CVS- distinct heart sounds, normal rate and rhythm
ABD- Flat, soft, Non-tender
EXT- CRT<2, strong pulses
A: URTI
P: 1. Multivitamins(Diavit): take 5 ml once a day

3. Arturo Amihan 49 yo/M
Mango ave., C.C.
wt.- 75 kg, HR- 82, RR- 20, Temp- 36.7
S: Patient was diagnosed with Gouty Arthritis for the past 10 yrs with maintenance medications which included
Allopurinol and Colchicine both with fair compliance. 5 yrs PTC, patient noted a painless nodular mass on the left
olecranon process which gradually enlarged to about 2 cm and had white and yellow deposits. Patient also
complained of joint pain mainly at the toes and fingers. Condition prompted consult.
O: Awake, NIRD
Skin- (+) tophi at Left Olecranon, 2 cm, non-tender
C/L- clear breath sounds
CVS- distinct heart sounds, normal rate and rhythm
ABD- Flat, soft, Non-tender
EXT- (+) swelling on Right Hand
A: Gouty Arthritis
P: 1. Obtain Serum Uric acid
2. Celecoxib 200mg tab: take 1 tab 2x a day

4. ZEPHANIAH MARIE DARAGOSA 17 y.o./F

S> One week PTA, patient noted undocumented intermittent low grade fever associated with urinary frequency and terminal
dysuria. She took Paracetamol (Biogesic) 500mg/tab 1 tab PO q4H PRN for fever which afforded relief and Cotrimoxazole
800mg/tab 1 tab BID PO for 3 days which afforded partial relief of symptoms, as claimed. Persistence of dysuria prompted this
consult.

O> Examined an awake, alert, afebrile, not in respiratory distress patient with the ff. V/s: BP= 120/80, HR= 80 RR= 20 T= 36.0.
Skin: warm, good turgor and mobility, no lesions
HEENT: anicteric sclerae, pink palpebral conjunctivae, no naso-aural discharges, no tonsillopharyngeal congestion
Neck: supple, trachea at midline, no lymphadenopathies
C/L: equal chest expansion, clear breath sounds, no rales/wheeze
CVS: distinct s1 and s2, normal rate, regular rhythm, no murmurs noted
GUT: (+) KPS, bilaterally
Ext: no edema, pink nailbeds, strong pulses
CNS: Within normal limits

A>Urinary Tract Infection

P>For Urinalysis
>Ciprofloxacin 500mg/tab 1 tab BID for 7 days
>Advised on proper hygiene
>Encourage oral fluids
>Follow up check up after 3 days with U/A results

May 23, 2014
1. ZEPHANIAH MARIE DARAGOSA, 17 y.o./F

S> Patient came in for follow up check-up with Urinalysis results. Ciprofloxacin taken with good compliance. Patient is ongoing
Day 4 of antibiotic meds. Dysuria lessened as claimed. No febrile episodes noted.

O> Examined an awake, alert, afebrile, not in respiratory distress patient with the ff. V/s: BP= 110/70, HR= 80 RR= 21 T= 36.5.
HEENT: anicteric sclerae, pink palpebral conjunctivae, no naso-aural discharges, no tonsillopharyngeal congestion
Neck: supple, trachea at midline, no lymphadenopathies

Urinalysis results (5/21/14)
Color: Yellow
Appearance: Cloudy
SP. Gr.: 1.020
pH: 5
Protein: +1
Blood: +1
Leukocytes: +1
RBC: 1-3/ hpf
WBC: 5-10/hpf
Epitheilial cells: Moderate
Bacteria: Abundant
Mucus threads: Rare

A>Urinary Tract Infection- Resolving
P>Repeat Urinalysis after completing full course of antibiotics
>Continue antibiotics for 3 more days
>TCB once with repeat U/A results

May 27, 2014
1. Polistico, Dylan 10 mo/M

S: Patient came in for follow-up. Had one febrile episode a day PTC, with highest recorded temperature of 38.4 C.
Patient was given Paracetamol 1 mL with relief. Patient still has productive cough with scanty, greenish sputum. No dyspnea,
tachypnea or retractions noted. Appetite is fair. No vomiting or changes in bladder and bowel habits.
O: alert, awake, afebrile, not in respiratory distress
Wt: 7 kg
T: 36.3 C
HR: 123 bpm
RR: 41 cpm
Skin: no lesions, warm to touch, good turgor and mobility
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no alar flaring, pink and moist lips and oral mucosa, no oral lesions
Neck: supple, no lymphadenopathy
C/L: ECE, clear breath sounds, no rales or wheezes
CVS: adynamic precordium, distinct S1 and S2, no murmurs
Abd: protuberant, soft, non-tender
Extm: no edema, strong pulses, CRT < 2 sec
A: Upper Respiratory Tract Infection
P: Labs:
CBC
Medications:
Paracetamol 120/5 4 mL q4 hours PRN for T > 38C (AD: 13.71 mkd)
Ambroxol 15/5 3 mL BID for 5 days (AD: 1.3 mkd)
Amoxicillin 100 mg/mL 1 mL TID for 7 days (AD: 42.85 mkD)
Continue Multivitamins OD daily
TCB: Friday, May 30, 2014 with labs

2. Flores, Cloemae 6 y.o./F

S> Three days PTA, patient was noted to have undocumented intermittent low grade fever associated with nonproductive
cough and loss of appetite. Persistence of condition prompted consult. No medication taken.
O> Examined an awake, alert, afebrile, not in respiratory distress patient with the ff. V/s: HR= 120 RR= 22 T= 37.0., Wt.= 16kgs
HEENT: anicteric sclerae, pink palpebral conjunctivae, no naso-aural discharges, (+) exudates on tonsils, bilateral
Neck: supple, trachea at midline, (+) submandibular lymphadenopathy, bilateral
GUT: (+) KPS, bilaterally

A>Acute Tonsillopharyngitis, Grade 2, Bilateral

P>For CBC and Urinalysis per request
>Amoxicillin (Moxylor) 250mg/5mL syrup 6mL TID x 7days (AD: 56.25 mkD)
>Paracetamol 250mg/5mL syrup 4mL q 4H PRN for fever
>Encourage oral fluids
>Continue vitamin supplements
>Follow up check up after 3 days with CBC and U/A results

3. Esmolo, Maribel 53/F
S> Tingling pain PS 10/10 on the left upper extremity, radiating to neck and sometimes to chest, noted to be worst at
night. This was noted 1 month PTC. Self-medicated with Mefenamic acid 500mg at night with temporary relief. No history
of blunt trauma on affected site, diagnosed hypertensive x2 years and taking Amlodipine 10mg 1 tab OD, with good
compliance, non-diabetic.
Esmolo, Maribel 53/F
O> BP: 130/80mmHg, HR: 65 RR: 18
weight: 61kg
Skin: warm, good turgor, no lesions
HEENT: no NVE, (+) excision scar on left side of neck
C/L: ECE, CBS
CVS: Adynamic precordium, distinct heart sounds, no murmur
Abd: Flabby, nontender
Extremities:
Left upper extremity:
No lesions, no signs of inflammation, full ROM, no tenderness
Distinct pulses, no edema
A>
1. T/C Diabetic Neuropathy
2. Essential Hypertension
P>
Diagnostics:
FBS, Lipid Panel, crea, BUA, 12-L ECG
Therapeutic Management:
1. Vitamin B1,6,12 (Neurobion) tab
2. Mefenamic acid 500mg tab, 1 tab PRN for pain
3. Amlodipine 10mg 1tab OD
-Advised proper diet and lifestyle modification
-TCB with lab results
June 3, 2014
1. Caballero, Diane

2. Ares, Zeth Ezykiel 2/M
Wt 10 kg
T 35.4 C
HR 124 bpm
RR 23 cpm

3 days PTC, patient had onset of coryza. No medications taken. 1 day PTA, condition associated with non-productive
cough. No fever, no anorexia.
C/L: clear breath sounds, (+) nasal discharge
A: URTI
P: Cetirizine (Alnix) 5/5 mL syrup 1 mL OD qhs x 7 days
Phenylpropamolamine (Sinudrin) 12.5/5 2.5 mL TID x 5 days

June 6, 2014
1. Torres, Katrina 1/F
S> Two days PTC, patient had onset of nonproductive cough associated with clear watery nasal discharges. No fever
noted. (+) dyspneic episodes

O> Examined patient asleep, afebrile, tachycardic, in respiratory distress, poor appetite with the following V/
S: HR= 160 bpm RR= 64 cpm T= 37 C/axilla
HEENT: anicteric sclerae, (+) alar flaring
C/L: (+) subcostal and intercostal retractions, (+) rales and wheeze on both lung fields, more on the left

A> PCAP-C

P> Advised admission
Salbutamol 1 neb 3x now then 15 mins apart
Cetirizine 2.5mg/5mL syrup 0.7 mL OD for 5 days
Cefuroxime 250mg/5mL 3.5 mL BID for 7 days with strict aspiration precaution
Budesonide neb 1 neb q 12H for asthma
Prednisone 20mg/5mL 0.8 mL BID for 5 days
Phenylpropanolamine 6.25 mg/mL drops 0.75 mL q 6H for 5 days

2. Demol, Diosada, 68/F
O: alert, awake, afebrile not in distress
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no alar flaring, moist lips and oral mucosa
C/L: no retractions, equal chest expansion, fine crackles both lung bases

A: Upper Respiratory Tract Infection
P: Encourage oral fluids

June 10, 2014
1. Valencia, Maxinne Cielo 5 mos/F
S> Pustules with erythematous borders on the outer ear and arm, noted to appear after applying liquid soap. Same incident
happened months prior, which was relieved by stopping the use of the offending agent. No fever, no loss of appetite. Applied
unrecalled cream with slight relief.
O> weight= 5kg temp: 36.5
HEENT: Pustules with erythematous borders on the outer ear
Ext: Pustules with erythematous borders on the left arm
A>Contact Dermatitis
P> Cetirizine 1mg/1ml suspension 0.5ml (AD 0.25) OD at bedtime
E-zinc 0.5ml OD
Calmoseptine ointment apply on affected site after every bath
TCB after 1 week.

June 13, 2014
NO CLINIC
June 17, 2014
1. Valencia, Maristela 42/F

2 weeks PTC, patient had onset of left lower quadrant pain with pain scale of 5/10 radiating to the back, no fever and
no vomiting.

1 week PTC, LLQ pain became worse, now associated with dysuria, no hematuria and no fever.

O> (+) left lower quadrant tenderness
(+) KPS Right, (-) KPS left
(-) Rovsing s sign, (-) obturator sign

A> UTI
P> For urinalysis
Sambong 1 tab TID for 14 days
Follow up on 6/20/14

June 20, 2014
1. Velasco, Ariane 4/F

2. Alburi, Krisna 4/F

S> Erythematous papules, non-pruritic. No cough, no coryza, no febrile episode, good appetite.
O> weight=15kg
Temp= 36.7
HEENT: Pustules with crust on scalp, (+) pruritus
EXT: Erythematous pustules some with crust, distributed throughout the body, (+)pruritus
A> Viral Exanthem
P> Cetirizine 1mg/1ml 3.5ml OD at bedtime x 7 days
Ff. up on Friday, June 27, 2014

3. Sanchez, Prince 6/M
S> Rashes generalized, including scalp, pruritic, no febrile episodes, good appetite.
O> HEENT: pustules with erythematous borders with some crusting on scalp area
C/L: CBS, ECE
EXT: pustules with erythematous borders with some crusting on both upper and lower extremities
A> Impetigo
P> Cloxacillin 125/5ml syrup 10ml TID x 7 days
Calmoseptine lotion apply to affected site BID after every bath
Advised proper hygiene

4. Valencia, Chezka 5/F
Wt 16 kg
T 38.8 C
HR 160 bpm
RR 23 cpm
On the day of consult, patients mother noted child to be feverish with undocumented temperature. (+) frontal
headache. No coryza, no cough, diarrhea or abdominal pain, vomiting or tachypnea. No complaints with urinary
patterns. No dysphagia or odynophagia.

O: irritable, febrile, not in respiratory distress
HEENT: anicteric sclerae, pinkish palpebral conjunctivae, no conjunctival suffusion, no tonsillopharyngeal erythema or
congestion
C/L: ECE, CBS
CVS: adynamic, DHS, tachycardic
Abd: soft, non-tender, resilient
Extm: no edema, no lesions, strong pulses, CRT < 2 sec
CNS: WNL

A: SVI
P: Paracetamol 250/5 4 mL po NOW then every 4 hours PRN for T > 38 C(AD: 12.5 mkd)

5. Caballero, Rosita, 67/F
Patient came in for hypertensive consult. Known hypertensive but with no maintenance medications. Highest SBP is
at 160 mmHg. No regular BP monitoring.

C/L: no retractions, equal chest expansion, fine crackles both lung bases

A: Essential Hypertension, Stage II, uncontrolled
P: Losartan 50 mg/tab 1 tab OD po daily
Regular BP monitoring, please keep record
Advised

6. Oyao, Magdalena 74/F

S> I day PTC, patient had blurring of vision, no headache and no vomiting. BP was taken which was 160/100 mmhg.
Metoprolol 10 mg 1 tab was taken to no avail hence sought consult.

BP: 160/100 mmhg, HR: 78, T: 36.2 C, RR: 20
C/L: no retractions, equal chest expansion

A: Essential Hypertension, Stage II, uncontrolled
P: Losartan 50 mg/tab 1 tab OD po daily
Regular BP monitoring, please keep record
Lipid panel

7. Oyao, Virginia 55/F

8. Allan Abella 4yo/Male

S> Non-productive cough and coryza x 1 day. Gave Cetirizine 5mg/5ml 3ml once with relief. No fever, no malaise, no
loose stools, good appetite.
O> RR: 22 HR: 78 Temp: 36.1
HEENT: moist lips and tongue, slight erythema on posterior pharynx, clear nasal discharge
C/L: Minimal wheeze on both lung bases, no retractions
A> URTI with asthmatic component
P> Salbutamol 2mg/5ml 2ml (AD 0.15) TID
Cetirizine 1mg/1ml 4 ml (AD 0.25) OD at bedtime
Phenylpropanolamine syrup2.5ml every 6hours
Follow up after 1 week.

June 24, 2014

1. Vin Diesel Padillo, 8 mos/M
S> A day PTC, started to have febrile episodes TMax=37.5 associated with clear nasal discharge, was given PCM
100mg/ml syrup 1 ml with temp.relief. Persistence prompted consult. Good appetite, no loose stools.
O> HEENT: petechial lesions on oral mucosa
C/L: CBS, ECE
A> Systemic Viral Infection
P> Cetirizine 1mg/ml syrup 1.25ml (AD 0.25) OD at bedtime
PCM 100mg/ml 0.7ml (AD 15) for temp >/= 37.5
ff. up on Friday 6/27/2014
TSB as needed

2. LIZA LICARDO 43/F

S> 5 days PTC, patient had cough and colds associated with intermittent fever and headache. She has yellowish
phlegm upon coughing and no dyspnea, took bioflu 1 tab but symptoms were not relieved thus sought consult.

O> awake, alert, cooperative and not in respiratory distress
C/L: equal chest expansion, (+) wheezing R lung field, no rales
A> URTI
P> Amoxicillin 500mg 1 tab TID x 7 days
Salbutamol 2mg 1 tab TID x 5 days
PCM +phenylpropanolamine chlorphenamine maleate 1 tab TID x 5 days
Follow up on Friday 6/27/2014

Consults

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May 6, 2014

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