SILLIMAN UNIVERSITY MEDICAL SCHOOL

PD-SURGERY WORKSHEET
SUBMITTED TO: Dr. Ceasar Ma. Raymund B. Rana, Jr.
SUBMITTED BY: Pajantoy, Al Inde John A.
Palomar, Christian Ayrton
Pasuquin, Alvin G.
Reyes, Edessa E.
Rodriguez, Arianne S.

DATE OF SUBMISSION: November 12, 2014

MEDICINEIII

REPRESENTATIVE CASE
Date and time of Interview. November 7, 2014 at 4:10 PM
Identifying Information: This is a case of YJ, 63 year old female, widow, a dressmaker, Filipino, Jehovas Witness, from
Barangay Pulantubig, Dumaguete City admitted on October 31, 2014 at around 10AM at Silliman Medical Center due to a painful
right gluteal lesion.
Source and Reliability. The patient herself. She was somehow clear enough in describing her symptoms and was able to specify
details.
Percent Reliability. 90 %
Chief Complaint: Painful right gluteal lesion.
HISTORY OF PRESENT ILLNESS: A week PTA, the patient noted a small, about the size of a pea, raised, fluid-filled lesion at the
inner lower quadrant of the right gluteal fold after frequent scratching. The area surrounding the lesion was warm, mildly
swollen and tender and she started having an intermittent, low-grade fever a day after the lesion appeared. The pain practically
worsens when she lies flat in her bed as well as during prolonged periods of sitting while doing her job as a dressmaker. To
alleviate the symptoms, she applied 70% ethyl alcohol and povidone-iodine (BETADINE WOUND SOLUTION) twice a day on the
affected area every after taking a bath, and took paracetamol (TEMPRA FORTE) 500mg tablet 3-4 times daily which afforded
temporary relief. No consultations were done and condition persisted.
A day PTA, the symptoms persisted and the patient noted that for the past few days the lesion was rapidly growing, about the
size of a pingpong ball, raised, hard and slightly indurated. The surrounding area was swollen, warm, erythematous and tender.
It was extremely painful, graded 9/10 in pain rating scale, and was very difficult for her to lie flat. These prompted her to seek
consult and was advised admission in preparation for an incision and drainage which will follow the next five days.
PAST MEDICAL HISTORY: Previous hospitalizations include:
(1993) Hemiplegia of the right leg and was diagnosed with Multiple sclerosis.
(1997) Diagnosed with myoma and had undergone TAHBSO
(2013) UTI
The patient was diagnosed with hypertension and diabetes mellitus last 2013 and was given gliclazide (DIAMICRON MR) 60mg
taken OD before breakfast, metformin hydrochloride (GLUMET) 500mg taken OD before supper and telmisartan,
hydrochlorothiazide (MICARDIS PLUS) 40mg taken OD. She is also taking multivitamins (CENTRUM SILVER) and ferrous sulfate
once daily. The patient has not been religiously compliant to her maintenance medications and would only take those
medications if she develops symptoms and also if she have extra money to buy them. No food and drug allergies.
Obstetric History: The patients obstetric score is G5P4(4013) and she had her menopause at the age of 46 during the time she
underwent TAHBSO for her myoma. No history of HRT use.
FAMILY HISTORY: The patients grandfather died of stroke and her parents are no longer living. The mother was known
hypertensive and her father died due to a liver disease. There is a family history of hypertension and diabetes mellitus. No other
history of heredofamilial diseases, to mention like arthritis, mental illnesses and cancer. No family history of infectious diseases
like tuberculosis, HIV and other sexually transmitted diseases.
PERSONAL AND SOCIAL HISTORY: The patient earns most of her living as a dressmaker, who works in her own shop from

8AM to 6PM. Her three children sometimes support her financial needs. Shes a non-smoker, non-alcoholic beverage drinker and
doesn't engage in illicit drug use. She eats a regular diet consisting vegetables, fish and meat and she doesn't follow her diet
restrictions.
PHYSICAL EXAMINATION
REVIEW OF SYSTEMS
General survey:
General: No changes have been noted on the
Patient is conscious, coherent, oriented to time, person and place.
patients general appearance. No weight loss or
Not in cardiorespiratory distress. T=36.7C, RR= 20cpm, HR= 76 BPM, BP=
gain, grooming, or dressing.
120/90mmHg on both arms. Appearance and Behavior: Prefers to stay in
bed most of the time, good grooming noted.
Skin: No changes in lesions noted as well in
complexion and texture of the skin.
Skin:
Color is pink, is warm and moist. Nails are without clubbing,
HEENT:
however, is pale. Capillary refill time= 2 seconds. No suspicious nevi. No
rash, petechiae or ecchymosis.
Head: Patient has no complaints of headache. She
did not notice any visible lumps or masses in the
HEENT:
head, no changes in hair texture and thickness.
Head: The skull is normocephalic/ atraumatic. Hair is black
(dyed), average texture and evenly distributed. No masses palpated on
Eyes: Patient has corrective eyeglasses but only
scalp.
uses it as necessary because of discomfort she feels
Eyes: White sclera and pink conjunctivae noted. Pupils are equally while wearing eyeglasses. No blind spots or
round, 2-3 mm in diameter, reactive to light and accommodation. (+)
diminishing lateral vision as claimed.
convergence.
Fundoscopic exam: Disc margins sharp; no hemorrhages or exudates, no
Ears: Patient claimed that she has diminished
arteriolar narrowing, no AV nicking.
ability to hear from afar although, she is coherent,
Ears: acuity good to whispered voice. Tympanic membranes with and able to follow instructions; no ear discharges
good cone of light. Weber midline.
and ear pain noticed or perceived in the past.
Nose: nasal mucosa pink, septum midline, no sinus tenderness. No
discharges.
Nose: No changes in smell as claimed, Patient
Throat/Neck: is supple. Trachea midline. Thyroid gland
claimed that she is able to breathe through the
nonpalpable. No masses. No enlargement of nodes.
nose, no growth, no obstruction noted.
Thorax/ lungs:
Thorax is symmetrical with good expansion. Lungs resonant.
Throat: No changes in the quality of voice, no
Breath sounds vesicular; no rales, wheezes or rhonchi. Diaphragmdescend dysphagia, no odynophagia, no sore throat
4cm bilaterally.
Neck: No neck pain noted, no painful lymph nodes
Cardiovascular:
as claimed by the patient.
No jugular venous distenstion. Carotid upstrokes are brisk,
without bruits. The point of maximal impulse is tapping, 7cm from the
Chest and Lungs: Has no difficulty of breathing,
midsternal line in the 5th intercostals space. No heart murmurs noted.
no chest tightness,
Abdomen:
No scars, striae or lesions on abdomen. No localized inflammation
or bulges on umbilicus, Abdomen round and symmetric. No obvious
masses. No pulsations. Bowel sounds at 12clicks/min. All other quadrants
with good bowel clicks. No bruits or friction rubs. Abdomen is tympanitic
on percussion. Liver span was 6 & 1/2 cm right MCL, with no tenderness
noted.Spleen and kidneys not felt. (-) KPS.
Peripheral vascular system:
Extremities are warm and without edema, except the right arm,
which is the insertion of IV site. No varicosities or stasis changes. Calves
are supple and nontender. No femoral or abdominal bruits. Brachial,
radial, femoral, popliteal, dorsalis pedis and posterior tibial pulses are
bounding and symmetric.
Musculoskeletal system:
No limitation in ROM, but weakness on Right and lower
extremities noted. No evidence of swelling, tenderness, or deformity. A
6x4 cm round lesion seen in the Right Lower Inner Quadrant of the gluteal
fold (Residents notes); post- op assessment not done since patient refused

Cardiovascular: No heaviness in the chest, and

racing heartbeats or palpitations noted, easy
fatigability noted especially when climbing threestep ladder.
Abdomen/ GIT: No changes in appetite. Bowel
movement every 2- 3 days due to her Multiple
Sclerosis; experiences slight difficulty and
discomfort in bowel movement; no changes in
stool color and consistency.
Genitourinary: Has urinary incontinence brought
about her Multiple Sclerosis. No vaginal
discharges, no lesion or ulcerations noted as
claimed. No flank pains.
Musculoskeletal: Patient is ambulatory with
right- sided weakness. Uses a cane to aid in
walking. No complaints of joint pains or muscle
stiffness.

to show the operative site.

Nervous system:
Mental status Exam:
LOC: Conscious, aware of the environment; Attention: Able to focus on
questions; Memory: Intact. Orientation: oriented to personal identity,
place and time; Perceptions: aware of objects in the environment;
Thought process: logical, and coherent; Thought content: Good; Affect:
Light; Mood: Happy ; Language: No speaking difficulty, fluent,
responsive to questions, and coherent.
Cranial Nerves:
Cranial nerve 1- Intact. Cranial II- visual acuity is intact; visual fields
full. Cranial III, IV, VI- extraocular movements intact. Cranial nerve Vtemporal and masseter with little strength sensory corneal reflexes
present; Cranial nerve VII- (motor) no facial palsy noted. Cranial nerve
VIII- hearing intact bilaterally to whispered voice. Cranial nerve IX, Xgag reflex present, soft palate rises symmetrically, Cranial nerve XIIno toungue deviation.
Motor system:
Right leg moves slower than the left leg. No involuntary movements.
No muscular atrophy. No floppiness or spastic muscles. Muscle
strength, right= paresis, left= 5/5
Sensory System:
Sensitivity to pain is bilaterally equal, temperature, light touch and
vibration intact on right and left, upper and lower extremities. Intact
position sense.
DTR:
Biceps: both 2+;
Triceps: both 2+;
Abdominal: 2+;
Knee Reflex, (R)-1+ (L)- 2+;
Plantar response: (R)- Babinski (-), (L)- Flexion

PRIMARY WORKING
IMPRESSION
Carbuncle, Right Gluteal
Area; lower quadrant

DIFFERENTIAL
DIAGNOSES
Erysipelas

Cellulitis

Neurologic: The patient is coherent and able to

follow command, memory intact. Claims that she is
oriented to time, date and place (thoroughly
verified).

RULE IN

RULE OUT

Hx: 63 y.o., diabetic, seamstress, (+) raised pea sized, fluid

filled lesion a week PTA following abrasions due to scratching,
(+) inflammation, (+) fever, lesion rapidly growing in the past
few days, (+) lesion was raised, hard and slightly indurated,
(+) 9/10 pain
P.E.: (+) Obese; A 6x4 cm round lesion seen in the Right Lower
Inner Quadrant of the gluteal fold (Residents notes); post- op
assessment not done since patient refused to show the
operative site.

Cannot be ruled out

RULE IN

RULE OUT

Hx: 63 y.o., diabetic, seamstress, (+) raised pea sized, fluid

filled lesion, lesion rapidly growing in the past few days, (+)
fever, (+) 9/10 pain
P.E.: (+) Obese, A 6x4 cm round lesion seen in the Right Lower
Inner Quadrant of the gluteal fold as verbalized by the resident
physician
Hx: 63 y.o., diabetic, seamstress, (+) raised pea sized, fluid
filled lesion a week PTA following abrasions due to scratching,
(+) inflammation, (+) fever
P.E.: (+) Obese, A 6x4 cm round lesion seen in the Right Lower
Inner Quadrant of the gluteal fold as verbalized by the resident
physician

Illness usually occurs 48

hours after initial infection, (-)
headache, (-) nausea and
vomiting
(-)edema, lesion rapidly
growing to a ping pong ball
mass in the past few days

LABORATORY AND DIAGNOSTICS

Labs to request
Normal values
Culture and sensitivity
Negative
testing

Purpose/Necessity
Culture is used to identify the
specific causative agent.

Cost
500

The sensitivity test shows which

antibiotic drugs should be used to
treat the specific causative agent
of the infection.

Complete Blood Count

Within normal limits

Blood typing and

crossmatching

Variable

Coagulation profile (e.g. PT

and aPTT)

PT: 12-14 seconds

aPTT: 28-38 seconds

This test is necessary because

many organisms are resistant to
certain antibiotics.
A complete blood count (CBC) is
used to detect or monitor many
different health conditions of the
patient:
Diagnose infections or allergies
Detect blood clotting problems
or blood disorders, including
anemia
Evaluate red blood cell
production or destruction
This test is used to determine the
ABO blood group and Rh type of
the patient. This is essential for
possible transfusions.
This profile is necessary to check
for the clotting tendencies and
clotting factor deficiencies of the
patient, especially that this is a
surgical case.

250

100

500

PT measures the extrinsic

pathway of coagulation. They are
used to determine the clotting
tendency of blood, in the measure
of warfarin dosage, liver damage,
and vitamin K status

Lipid profile

LDL cholesterol:
lower than 130
mg/dL
HDL cholesterol:
greater than 40 to 60

The principal clinical uses of the

aPTT include: (1) the detection of
hereditary or acquired
deficiencies or defects of the
intrinsic coagulation factors
(Factors XII, XI, IX, VIII,
prekallikrein, high molecular
weight kininogen), (2)
monitoring heparin anticoagulant
therapy, (3) the detection of
coagulation inhibitors (i.e., lupus
anticoagulant), and (4) to
monitor coagulation factor
replacement therapy.
Lipid profile will help us better
understand the risk for heart
disease, stroke, and other
problems caused by blocked

720

mg/dL (higher
numbers are desired)
Total cholesterol: less
than 200 mg/dL
Triglycerides: 10 to
150 mg/dL
VLDL: 2 to 30 mg/dL

arteries.

Fasting Blood Sugar

75120 mg/dL

Random Blood Sugar

79 - 140 mg/dl

Hemoglobin A1C

4 6 mg/dL

FBS is used to help diagnose

diabetes mellitus and
hypoglycemia.
A blood sugar test taken from a
non-fasting subject. RBS assumes
a recent meal and therefore has
higher reference values than the
fasting glucose test.
The hemoglobin A1C test is a
valuable measure of the overall
effectiveness of blood glucose
control over a period of time. This
is usually measured every 2 to 3
months. The key value is the
percentage of hemoglobin in red
blood cells that is coated in sugar.

Urinalysis

Normal

Kidney Function Tests

Creatinine - 0.7-1.4 g/dL

BUN - 6 - 20 mg/dL

These tests are necessary

considering that the patient is at
risk for developing cardiac
problems because she has a
family history heart disease.

When the 3 tests (RBS, FBS,

HgBA1C) are combined, they give
a fairly accurate picture of the
state of glucose control in a
diabetic patient.
A urinalysis is advisable to be
done in this patient for various
purposes:
As part of a routine
medical exam to screen
for early signs of disease
To evaluate signs of
diabetes or kidney
disease, or to monitor
response to treatment in
these conditions
To check for blood in the
urine
To diagnose a urinary
tract infection
Kidney function tests are
common lab tests used to
evaluate how well the kidneys are
working. Such tests include:
BUN
Creatinine - blood
Creatinine clearance
Creatinine - urine
The patient is diagnosed with
Diabetes Mellitus type 2, and
diabetes can pose a multisystem
danger, so it is vital to check
other organs as well (e.g. kidney)

140
200

630

50

300

Liver Function Tests

SGPT - 21-72 IU/L

Chest x-ray

Unremarkable

ECG

normal sinus rhythm

normal QRS axis
normal P waves
normal PR interval
normal QRS complex
normal QT interval
normal ST segment
normal T wave
normal U wave

To see how well the liver is

working specially with the
medications taken by the patient
which maybe hepatotoxic, posing
a threat to the liver.
This is a procedure used to
evaluate organs and structures
within the chest for symptoms of
disease and to check the effects of
hypertension to the heart.
The electrocardiogram (ECG or
EKG) is used to reflect underlying
heart conditions by measuring
the electrical activity of the heart.

240

350

400.00

This should be done in this

patient for purposes of
cardiopulmonary clearance and
because the patient is of
advanced age with a family
history of heart disease.
FINAL DIAGNOSIS: Carbuncle, Right Gluteal Area; lower quadrant to consider Staphylococcus aureus infection

LIST OF PROBLEMS:
1. hyperglycemia
2. hypertension
3. carbuncle
4. on and off fever
5. 9/10 level of pain in the right gluteal area
6. history of multiple sclerosis
7. blurring of vision
8. easy fatigability
9. urinary incontinence
10. poLydipsia
11. polyuria
12. polyphagia
13. right cervical lymph node tenderness
14. pale conjunctiva

THERAPEUTICS
THERAPEUTIC OBJECTIVES:
1. To treat hyperglycemia with blood sugar lowering drugs and
monitor compliance of medications.
2. To treat hypertension with BP-lowering drugs and monitor
compliance of medications.
3. To treat carbuncle with the specific antibiotic for a certain
causative agent.
4. To treat the intermittent fever with antipyretics
5. To relieve pain within the carbuncle with pain relievers.
6. To prevent/and or reduce the chances or recurrence of
multiple sclerosis
7. To remedy the blurring of vision by controlling Diabetes
Mellitus and giving of the right refractive lenses.
8. To treat other symptoms of Diabetes Mellitus like polydipsia,
polyphagia, and polyuria.
9. To treat any signs of iron deficiency with iron supplements.

MANAGEMENT
Advice and Information
Educate patient and family about her condition: possible etiology, risk factors, course of disease,
signs and symptoms, complications if left untreated, prognosis and medical options for treatment
including its benefits, side effects, risk and alternatives. Increasing patients knowledge about her
condition to improve medical compliance and assist in symptom management.
Emphasize that precise diabetic control is, of course, vital, not only in achieving resolution of the
current wound, but also in minimizing the risk of recurrence.
Emphasize importance of medication compliance in optimum management of her condition.
Teach the patient on how to do self-monitoring of blood sugar
Advice patient to have a life style modification: Diet & exercise
Advise the patient to have a diabetic, hypertensive diet. ( low salt, sugar, fats and high protein)
Advice the patient to have at least 30-45 mins of exercise per day for 3-5 days.
Advice the patient about proper personal hygiene, medical handwashing and wound care
Advice the patient to seek medical attention if there are any signs of possible complications
(infection, bleeding, fatigue, angina, retinopathy and kidney problems).
Non-pharmacologic Management
Preoperative Management
Admit to ward
Vital signs monitoring q 4h
Start IVF PNSS 1L @ 33 gtts/min
Insert FBC
Allow the patient the opportunity to ask any questions and address any concerns they may have. Make sure that they
have an understanding about the procedure so they can make an informed decision.
For surgical evaluation; If the patient's physical condition is compromised, stabilization to render her fit for
anesthesia should be carried out before incision, drainage and debridement are undertaken.
Surgical Management
Incision and Drainage with Debridement of the necrotic center
The surgical incision allows the pus and slough to drain. The necrotic center is debrided while the surrounding
cellulitis is not excised. The aim of debridement is to create an acute wound milieu so as to trigger the bodys natural
wound healing mechanisms and thereby promote healing. The surrounding inflamed tissue is not excised but is
instead treated with a course of antibiotics. Similarly, it is dressed until it heals by secondary intention. It also
preserves the surrounding inflamed tissue that is later treated with antibiotics, thus the resultant wound is smaller.

Post-operative Management
Maintain the individual on a pressure-redistribution system to reduce shear and pressure on the gluteal area.
Monitor site signs of bleeding.
Monitor site for edema, changes in color, drainage, temperature changes, pain.
Assess gluteal area for carefully for signs of infection and delays in healing,
Maintain skin integrity to the extent possible.
Monitor vital signs
Bed rest.
Reposition and turn the individual at periodic intervals, in accordance with the individuals wishes and tolerance.
Control wound odor. Cleanse the surgical site and surrounding skin at the time of each dressing change.
Provide adequate nutrition for healing. Diabetic, low salt and low fat diet.
IVF PNSS 1L
PHARMACOLOGIC MANAGEMENT
Drug Name
Efficacy
Safety
Suitability
Cost
ANTIMICROBIAL
Clindal is a semisynthetic
Gastrointestinal
Clindal reduces the
lincosamide antibiotic that has
disturbances are
toxin producing
P19.00/cap
largely replaced lincomycin due to
reported. Esophageal
effects of S. aureus
an improved side effect profile.
ulceration may be a
and S. pyogenes and
P1900.00/box
Clindamycin
Clindal inhibits bacterial protein
particular problem if
as such, may be
(Clindal)
synthesis by binding to bacterial
capsules or tablet are
particularly useful for
600mg IV q 6
50S ribosomal subunits. It may be
taken with insufficient treating necrotizing
(ANST)
bacteriostatic or bactericidal
fluid or in a
fasciitis.
depending on the organism and
recumbent posture.
drug concentration.
Pruritus and skin
rashes may occur.
Ciprofloxacin is a broad-spectrum
The most frequently
Ciprofloxacin is used
antibiotic active against both
reported drug related
to treat a wide
Ciprofloxacin
Gram-positive and Gram-negative
eventS for all
variety of infections,
(Ciprobay)
bacteria. It functions by inhibiting
indications of
including infections
IV Infusion
DNA gyrase, a type II
ciprofloxacin therapy
of skin, skin
containing 2,54 mg topoisomerase, and topoisomerase were nausea, diarrhea, structures, bones and
ciprofloxacin
IV, enzymes necessary to separate
vomiting and rash
joints, endocarditis,
lactate equivalent
bacterial DNA, thereby inhibiting
gastroenteritis,
to 2,0 mg
cell division.
Warning
malignant otitis
ciprofloxacin per
CIPROBAY should be
externa, respiratory
mL in 0,9% sodium
used with caution in
tract infections,
chloride solution.
patients with a history cellulitis
of convulsive
disorders
FOR DIABETES
Contraindications
Contraindicated in
patients during
episodes of
hypoglycemia and
in patients
hypersensitive to
Humulin R (insulin
(human
recombinant)) U100 or any of its
excipients.

Insulin is indicated as an
adjunct to diet and exercise
to improve glycemic control
in adults and children with
type 1 and type 2 diabetes
mellitus

100 u/ml 10 ml
vial
(P1200.00)

Insulin (Humulin R)
10 units subQ every
6 hours

Insulin regular is a short-acting insulin.

When subcutaneously administered, the
onset of action (as evidenced by a
decrease in glucose level) occurs 30
minutes post-dose. Maximal effect
occurs between 1.5 and 3.5 hours postdose. The glucose-lowering effect occurs
8 hours post-dose. Compared to other
rapid-acting insulin analogs, insulin
regular has a slower onset of action and
longer duration of action.

Metformin
(Humamet)
500 mg P.O TID

Metformin is an oral
antihyperglycemic agent that
improves glucose tolerance in
patients with NIDDM, lowering both
basal and postprandial plasma
glucose. Metformin is not chemically
or pharmacologically related to any
other class of oral

Contraindicatio
ns
Contraindicated
in people with
any condition
that could
increase the risk
of lactic acidosis,

Metformin is used as an
adjunct to diet and
exercise in adult patients
(18 years and older) with
NIDDM.

500 mg tab
60s/pack
(P564.00/pack)

antihyperglycemic agents. Unlike

sulfonylureas, metformin does not
produce hypoglycemia in either
patients with NIDDM or healthy
subjects and does not cause
hyperinsulinemia. Metformin does
not affect insulin secretion.

including kidney
disorders
(creatinine levels
over 150 mol/l
(1.7 mg/dL), lung
disease and liver
disease.

PAIN MANAGEMENT

Paracetamol
Biogesic
300 mg IV q 4h prn
for T > or equal to
38C

It is a nonsteroidal antiinflammatory drug that

exhibits analgesic and
antipyretic activities by
inhibiting prostaglandin
synthesis that may serve as
mediators of pain and
fever, primarily in the CNS.

This should be
contraindicated to those
who ingested products
containing alcohol. It is
contraindicated to those
with previous
hypersensitivity to
ibuprofen and related
compounds. Adverse
reactions include asthma,
urticaria or allergic-type
reaction following NSAID
administration

Relief to mild to
moderately severe pain of
musculoskeletal origin eg
muscle pain. It is also
indicated to reduce fever.

MONITORING AND FOLLOW-UP

Repeat laboratory exams for treatment evaluation such as blood culture and sensitivity, X-ray, CBC
and Glycolylated and Fasting Blood Sugar
Monitor site for signs of infection and progress of wound healing.
VS q 4 hours
Evaluate patient 7-10 days after discharge for re-evaluation.

500's
(P1429.08/pac
k)
Biogesic oral
susp 250 mg/5
mL- 60 mL x
1's
(P87.28/bottle
)

PRESCRIPTION:

Alvin Pasuquin, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________

___________________________
SIGNATURE
Christian Palomar, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:_____________________________ Date: ________________

___________________________
SIGNATURE

Al Indie Pajantoy, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________

___________________________
SIGNATURE
Edessa Reyes, MD
Silliman University Medical Center
Name:________________________________ Age/Sex:______________
Address:___________________________ Date: ________________

___________________________
SIGNATURE

REFERENCES:
References:
Braunwald et. al. 2008. Harrisons Principles of Internal Medicine. 18th ed. McGraw Hill Companies, USA.
Fauci, A., et al. (2008). Harrisons Principles of Internal Medicine. 17th Ed. McGraw-Hill Medical Publishing Division, United
States of America
Katzung, B. (2007). Basic and Clinical Pharmacology. 10th Ed. Lange McGraw-Hill. USA
Kee, J.L. & Hayes, E.R. 2003. Pharmacology A Nursing Approach. 4th ed. Elsevier Science, USA.
MIMS Philippines. 113th Ed. 2007
Strandell, C. et al. (2000). Manual of Laboratory and Diagnostic Tests. 6th Ed. Lippincott Williams & Wilkins. Philadelphia.