QUIRINO MEMORIAL MEDICAL CENTER

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY CENSUS

DECEMBER 7-8, 2019
ORANGE TEAM
RESIDENTS: DR DOLOIRAS/BEJOSA/MADRASO/ULANDAY/MURAO/SISON/SANGALANG/LEONIDO/RENDON/COMIA/BELOCURA/CUNANAN/VALEROSO/JANORAS/DE VILLA/TIZO-PILAY
G ROOM A
NAME | DOB HOSPITAL DATE OF AGE CONSULTANT | TEAM DIAGNOSIS MEDICATIONS HOSPITAL ORDERS
NUMBER ADMISSION RESIDENT DAYS
1. PRENATAL MVT OD 9 BP: HR: RR: TEMP: O2:
VS
ENRIQUEZ, JANET 1085335 11/29/2019 40 DR. MORALES/ ORANGE G4P3 (3003) PU 29W 2. CALCIUM TAB BID 110-130/80-90 72-90 18-21 35.7-36.9 98-99%
GABAT SANGALANG 1D AOG BY UTZ; 3. MORIAMIN TAB OD I: 2900
27W 6D 4. ASPIRIN 100MG TAB OD O: 2600
06/21/1979 ACUTE 5. CEFIXIME 200MG/TAB BID FHT: 120S - 140S
PYELONEPHRITIS- X 7 DAYS
12/3 NST REACTIVE RESOLVING 6. TRIHEMIC TAB OD LABS:
7. FOLIC ACID TAB OD 12/07 CREA 85.87
(-) CVA CHRONIC 8. PARACETAMOL 500 12/6 CREA 99.68
TENDERNESS HYPERTENSION MG/TAB PRN 12/5 CBC 96.0/ 0.28/ 11.6/ 484
(-) HEADACHE -CONTROLLED 12/5 SGOT 20.90/ SGPT 15.62/ BUN 6.43/ CREA 126.24/ LDH 136.36
(-) BOV DEXAMETHASONE 6MG TIM 12/2 NA 138.12, K 4.34, SGOT 18.41, SGPT 10.75, BUN 4.92, CREA 119.39, LDH 182.20
(-) EPIGASTRIC S/P CVD INFARCT Q12 - COMPLETED (12/3 12/2 CBC 92/0.27/13.9/365/ MCV 89.80/ MCH 30.90/ MCHC 34.40/ RDW 13
PAIN (2016) 4AM) 12/1 24 HOUR URINE VOLUME - 1000/ 24 HOUR URINE CHON – 70
11/30 CREA 145.73
LAST FEBRILE T/C IDA 11/29 CBC 102/ 0.30/ 22.9/ 336
EPISODE: 12/01/19 11/29 UA YELLOW/ SL. TURBID/ 6/ 1.02/ 2+/ NEG./ 3-40/ 8-10
AKI PROBABLY SEC 11/29 BUN 4.61/ CREA 125.85
DAY 6 AFEBRILE TO INFECTION ON 11/29 URINE GS G(+) COCCI IN CLUSTERS, MODERATE; WBC 15-20; EPITHELIAL FEW
TOP OF PROBABLY 11/29 URINE CS NO GROWTH
CKD SEC TO
POLYCYSTIC KIDNEY 12/06 BPS:
DISEASE BPS 8/8

12/06 PBS:
NORMOCYTIC, NORMOCHROMIC RED BLOOD CELLS WITH ECHINOCYTES,
CODOCYTES AND ROULEAUX FORMATION. THERE IS NEUTROPHYLIC LEUKCYTOSIS.
NO BLAST CELLS SEEN. PLATELETS ADEQUATE.

UTZ 11/29:
SLIUP, 27W3D, BREECH, AFI: 16.88, PLACENTA ANTERIOR GRADE 2, AC IS 2 WEEKS
OFF EXPECTED AT AOG – 21.83CM
SUGGEST REPEAT SCAN AFTER 2 WEEKS EFW: 895G

UTZ 12/02:
SLIUP 27 WEEKS 5 DAYS BY BIOMETRY, CEPHALIC, ADEQUATE AMNIOTIC FLUID
(19.68), EFW: 1040GRAMS
DOPPLERS: UTERINE ARTERIES SHOWED NORMAL INDICES, SUGGESTIVE OF
ADEQUATE BLOOD FLOW IN THE UTEROPLACENTAL CIRCULATION. UMBILICAL
ARTERY SHOWED NORMAL INDICES SUGGESTIVE OF OPTIMAL BLOOD FLOW IN THE
FETOPLACENTAL CIRCULTAION.

KUB INITIAL 12/5/19

POLYCYSTIC KIDNEY DISEASE, NON-OBSTRUCTING NEPHROLITHIASES IN THE LEFT
WITH DEBRIS IN THE LEFT RENAL PELVOCALYCEAL SYSTEM MAYBE HEMORRHAGIC
OR INFECTIOUS, BILATERAL URETEROPELVOCALIECTASIA MAYBE SECONDARY TO
COMPRESSION OF THE GRAVID UTERUS, URINAY BLADDER WITH DEBRIS MAYBE
DUE TO HEMORRHAGE OR INFLAMMATION

12/7 AWAITING NEPHRO NOTES (FOR CLEARANCE PRIOR TO D/C)

12/07 PERINAT NO OBJECTION FOR DISCHARGE
FFUP AT PERINAT OPD ON 12/16/19 WITH BPS
.

CATAN, ROXANNE 1323323 12/4/2019 35 DR. VERGARA/S ORANGE G4P3 (3003) PU 23W 1. DEXAMETHASONE 6 MG 4 BP: HR: RR: TEMP: O2:
PRUDENCIO ISON AOG BY LMP, NIL; TIV Q12 X 4 DOSES - COMP VS
140-170/80-100 64-79 18-23 36.1-36.8 95- 99
22W4D 2. MGSO4 DRIP 4 CC + PNSS I:2100
4/28/1984 CHRONIC 96 CC Q1 X 24 HRS - O: 1700
HYPERTENSION - DISCONTINUED FHT: 120-140S
UNCONTROLLED 3. NICARDIPINE DRIP 90 CC +
ADMITTING BP: 10 MG NICARDIPINE VIA LABS:
180/120 HYPOKALEMIA – SOLUSET TO RUN AT 5 12/07 3.74
ONGOING UGTTS/ INCREMENTS OF5 12/5 TSH 0.49/ FT3 3.81/ FT4 1.2
CORRECTION UGTTS TO MAINTAIN SBP 12/4 CBC 140/0.40/14.8/326
140-150 - DISCONTINUED 12/4 NA 133.69/ K 2.70/ SGOT 21.73/SGPT 10.99/BUN 3.96/CREA 56.95/LDH 273.64
 4. METHYLDOPA 250 MG/TAB,
3 TABS Q8
5. CALCIUM TAB TID
6. ASPIRIN 10 MG/TAB OD
KCL DRIP AND TAB DONE
12/4 PT 11.2/ INR 0.84/ PT NC 13.2/ APTT 28.0/ APTT NC 27.2
12/4 UA LY/ SL TURBID/ 7.5/ 1.015/ 3+/ TRACE/ 0-2/ 10-15
12/5: UTZ: SLIUP, 23WEEKS 1DAY, CEPHALIC, WITH GOOD CARDIAC AND SOMATIC
ACTIVITIES, PLACENTA ANTERIOR GRADE 2, ADEQUATE AMNIOTIC FLUID (8.43CM),
EFW 593G

12/07 DISCONTINUE NICARD DRIP

AWAITING OPHTHA NOTES

PLATERO, 530223 12/06/2019 33 DR. POTIAN/ YELLOW G3P2 (2002) PU 1. PRENATAL MVT OD 2 BP: HR: RR: TEMP: O2:
VS
ELEANOR SANTOS 22W3D AOG BY EUTZ; 2. FESO4 TAB OD 130-150/90-100 92-95 20-22 36.1-36.5 96-99
CAPELLAN NIL; 3. METHYLDOPA 250MG/TAB I: 3000
Q8 O: 1700
10/05/1986 PES WITH SEVERE 4. CALCIUM 600 MG/TAB Q8 FHT: 130S
FEATURES 5. ASA 80 MG/TAB OD
ADMITTING BP: LABS:
170/100 12/06 CBC 121.0/ 0.37/ 9.6/ 313
12/06 HBA1C 5.51
12/06 PT 13.2, PTT 31.6
12/06 NA 137.46, K 3.40, AST 14.31, ALT 10.72, BUN 2.64, CREA 35.68, LDH 136.72
12/06 UA Y, C, 7, 1.005, NEG, NEG, 1-3, 0-1

12/06 FOR CAS ON MONDAY

12/07 OPHTHA
NO OPHTHA INTERVENTION FOR NOW
ENSURE STRICT BP CONTROL
OPHTHA SIGN OUT
ARRIESGADO, 765333 12/06/2019 34 DR. POTIAN/ YELLOW G4P3 (3003) PU 1. DEXAMETHASONE 6 MG 2 BP: HR: RR: TEMP: O2:
VS
PINKY MATIENZO SANTOS 33W5D AOG BY EUTZ TIV Q12 X 4 DOSES 100-110/60 98-105 21 36.3-36.4 98-99
(18W) CEPHALIC, PCS COMPLETED I: 2300
06/18/1985 X 2 FOR UNKOWN O: 2000
INDICATION & FHT: 130-150S
REPEAT (2011, ST.
(-) VOMITING VICTORIA, 2012, LABS:
(+) LBM QMMC) 12/06 CBC 128.0/ 0.38/ 11.6/ 290
12/06 NA 135.37, K 3.48, CL 108.86
AGE WITH NO SIGNS 12/06 UA LY, C, 6.5, 1.005, NEG, NEG, 8-10, 0-2
OF DEHYDRATION
12/07 FOR FECALYSIS
LABOR WATCH Q6
PMGH TODAY IF WITH NO LBM
PITUGO 542654 12/07/2019 28 DR PUNZALAN/ ORANGE G3P2 (2002) PU 26W 1 PRENATAL MVT OD 1 BP: HR: RR: TEMP: O2:
VS
LUNINGNING BELOCURA 4D AOG BY LMP, ONG 2 FESO4 TAB OD 100/60 87 21 36.7 98
GALLARDO BILATERAL I: 1000
O:800
12/21/1990 FHT 130S
12/07 PT 13.5 INR 1.02 PTT 28.8
12/07 NA 138.01 K 3.39 CL 109.04
12/07 CBC 118 ,0.34, 11.9, 261

MAURE RUTH 1323503 12/07/2019 24 DR ORANGE G2P1 (1001) PU 22W 1 PRENATAL MVT TAB OD 1 BP: HR: RR: TEMP: O2:
VS
TABUNP PUNZALAN/BEL 4D AOG BY LMP NIL 2 PARACETAMOL 500 MG TAB 100/60 107 22 37.6 98
OCURA DENGUE W/O Q4 PRN I:1200
03/30/1995 WARNING SIGNS O:900

12/07 CBC 104 0.32, 5.2, 137

12/07 Y/ST/ 6/ 1.03/ 2+/ NEG/ 0-2/ 2-4
12/07 DENGUE IGM IGG NEGATIVE NS1 ANTIGEN POSITIVE
12/07 CBC 99/0.29/ 5.7/ 133
12/07 PT 12.9 INR 0.98 PTT 34.1
12/07 NA 131.83 K 3.43 CL 103.96 AST 52.73 ALT 33.03

12/07 AWAITING OB IDS NOTES

OLASE, MA. 062684 12/07/2019 38 DR DEMESA/ YELLOW G5P4 (4004) PU 31W 1 AMPICILLIN 2G TIV ANST Q6 1 BP: HR: RR: TEMP: O2:
VS
EMELITA GAUFO CHUA 1D AOG BY EUTZ 17W D2 90/60 92 19-22 36.3-36.7 97-98
6D PCS X1 (2002 2 DEXAMETHASONE 6MG IM I: 2500
09/19/1981 QMMC S/P VAAC 2005 X4¾ O: 2400
QMMC) PROM X 30H 3 ERYTHROMYCIN 500MG FHT 140-150S
TAB Q8 D2

2
 MGSO4 4CC + 96CC PNSS X
1H X 24H CYCLES 12/07 NA 135.12, K 3.95, BUN 1.71, CREA 45.82 LDH 244.41
12/07 L.Y/ C/ 7.5/ 1.01, NEG, NEG, 3-4 0-2
12/07 CBC 90, 0.29, 12.5, 257

12/07 FF UP URINE GSCS

FOR BPS ON MONDAY

TOSIO VANESSA 1310005 12/07/2019 21 DR DEMESA/ YELLOW G1P0 PU 34W AOG BY 1 DEXAMETHASONE 6MG TIV 1 BP: HR: RR: TEMP: O2:
MAE NAZARENO CHACON UTZ PRETERM X 4 DOSES ¾ VS
90-100/70 78-84 17-20 36.2-36.7 100
05/27/1998 LABOR 2 NIFEDIPINE 10MG TAB Q6 I: 1700
UNTIL DEXA COMPLETED O: 1500
NST REACTIVE 3 FESO4 TAB OD FHT 120S-140S
4 PRENATAL MVT TAB OD
12/07 Y/H/7.5/1.01, NEG, NEG, 1-3, 6-8
12/07 CBC 107, 0.34, 19.9, 444

12/07 FOR BPS ON MONDAY

CALVARIO APPLE 1323442 12/06/2019 29 DR POTIAN/ YELLOW G1P0 PU 34W 2D AOG 1 METHYLDOPA 250MG TAB 2 8 BP: HR: RR: TEMP: O2:
LORIE MANANGBAO 34W SANTOS BY EUTZ NIL TABS Q6 VS
140-150/80 88-110 22 37.9 98
10/13/1990 GH R/O PES 2 HYDRALAZINE TIV I:2700
3 DEXAMETHASONE 6MG IM O: 2500
OVERT DM INSULIN X4 DOSES COMPLETED FHT 130S
REQUIRING MGSO4 4CC+ 96CC PNSS VIA
UNCONTROLLED SOLUSET X 1 HRCOMPLETED 12/07 IMK ENDO
4 KCL TAB TID FOR HBA1C FBS TLP CPEPTIDE UA
5 FESO4 TAB START REGULAR INSULIN SLIDING SCALE
6PRENATAL M,VT OD 130-170 2UNITS
171-220 4 UNITS
221-240 6 UNITS
241-260 8 UNITS
261-300 10 UNITS
301-340 12UNITS
MONITOR CBG PRE BFAST & 2HRS POST MEAL TID Q4 IF NPO
REFER TO DIETARY
VITUG EDERLYN 126082 12/07/2019 26 DR PUNZALAN ORANGE G3P2 (2002) PU 10W 1 METHYLDOPA 250MG TAB 1 BP: HR: RR: TEMP: 02 SAT:
BANARES BELOCURA 3D AOG BY LMP OD-DEFER VS
90-100/60 72-92 18-22 36.1-37.1 95-99
05/04/1993 CH UNCONTROLLED 2 CALCIUM TAB TID I:1100
3 ASPIRIN 100MG TAB OD O:900
4 FOLIC ACID TAB OD
12/07 NA 138.70, K 3.33, CL 104.03, AST 35.47, ALT 44.15, BUN 1.98, CREA 38.31, LDH
144.36
12/07 PT 12.8 INR 0.97, PTT 26.5
12/07 CBC 125, 0.36, 11.9, 319
12/07 Y/H/6.5/ 1.01/ 1+/ NEG, 0-2/ 3-8

12/08 AWAITING OPHTHA AND CARDIO NOTES

DEFER METHYLDOPA FOR NOW

ROOM B
NAME | DOB HOSPITAL DATE OF AGE CONSULTANT | TEAM DIAGNOSIS MEDICATIONS HOSPITAL ORDERS
NUMBER ADMISSION RESIDENT DAYS
DREW, AEREAN 1008906 12/04/2019 21 DR APEPE/ YELLOW G3P2 (2002) PU 26W 1 CEFUROXIME 2G TIV OD - 4 BP: HR: RR: TEMP: 02 SAT:
VS
ROGEL DR. LIMJOCO AOG NIL, HOLD 90/60 72-92 18-22 36.1-37.1 95-99
2 AZITHROMYCIN 500MG TAB I: 2800
11/09/1988 PCS X 2 OD -HOLD O: 2500
MALPRESENTATION, 3 PRENATAL MVT FHT 120S-140S
(+) FEBRILE REPEAT (2016, 2018 4 FESO4
EPISODE 38.9C QMMC) PARACETAMOL 500MG TAB LABS:
Q4 PRN 12/07 CBC 107, 0.33, 7.2, 100
DENGUE FEVER 5. PARACETAMOL 300MG IV 12/5 CBC 107.0/ 0.32/ 5.6/ 122
WITHOUT WARNING Q4 12/05 K 3.11
SIGNS 6. NAC 600MG TAB 12/05 DENGUE 1GG NEG/ 1GM NEG/ NS1 POS
12/05 CBC 104,0.32, 5.0,118
12/04 NA 133.79, K 2.79, CL 104.26, BUN 1.06, CREA 32.77
12/04 LIGHT YELLOW, SLIGHTLY TURBID, 7, 1.005, TRACE, NEG ,0-2, 2-4
12/04 CBC 112, 0.34, 6.8, 169

3
 12/03 YELLOW CLEAR 7.5, 1.005, NEG, NEG, 0-1, 2-4,
12/04 CBC 116, 0.35, 177, 6.3

12/5 UTZ: SLIUP, 28WEEKS 6DAYS, CEPHALIC, WITH GOOD CARDIAC AND SOMATIC
ACTIVITIES, PLACENTA LEFT POSTERIOR GRADE 2, ADEQUATE AMNIOTIC FLUID
(10.49CM), EFW 1301G

12/07 PMGH ONCE WITH INC. TREND OF PC

12/07 OB IDS FOR SGOT SGPT
CONT MGT
TUANG-TUANG, 1321425 12/04/2019 23 DR. VERGARA/ ORANGE G2P1(1001) PU 35W 1D DEXAMETHASONE 1GM X 4 4 BP: HR: RR: TEMP: 02 SAT:
VS
DENLYN SISON AOG BY LMP, DOSES Q12 - COMPLETED 90-120/60-70 65-109 18-20 36.3-36.7 98-99
FESO4 OD I: 1600
12/05/1996 CIPTL MULTIVITAMINS TAB OD O: 1400
FHT 120-140S
ADMITTING IE: GDM CONTROLLED
2CM/50%/CEPH/-3/ CBG 6AM 90/ 6PM 100/ 8PM 110
+BOW
LABS
12/05 CBC: 130, 0.39,16,1, 241
12/05 HBA1C: 4.95
12/05: T3 3.24, T4 0.81, TSH 0.64

12/05 UTZ: SLIUP, 35WEEKS 2DAYS, CEPHALIC, WITH GOOD CARDIAC AND SOMATIC
ACTIVITIES, PLACENTA POSTERO-FUNDAL GRADE 2-3, ADEQUATE AMNIOTIC FLUID
(13.76CM), EFW 2817G, BPS 8/8
12/7 CONT CGB MONITORING FOR DAILY NST

MORALES, HANNA 1323234 12/02/2019 15 DR. PERALTA/ BLUE G1P0 PU 28W AOG BY FESO4 TAB OD 6 BP: HR: RR: TEMP: 02 SAT:
VS
MAE ALISOSO ROASA LMP; CIPTL PRENATAL MVT OD 90-100/60-70 76-103 19-23 36.1-37.0 98-99
PROGESTERONE SUPP I: 1900
05/03/2004 T/C CONDYLOMA ODHS O: 1600
ACUMINATA FHT 120S-150S
ADMITTING IE: 4 CM/ DEXAMETHASONE 6MG X 4
50%/ C/ -2/ (+) BOW YOUNG PRIMIGRAVID DOSES COMPLETED
MGSO4 4CC+ PNSS 96H X 1H LABS:
X 24H COMPLETED 12/03 CBC 113.0/ 0.35/ 22.5/ 447
12/03 PT 13.8, PTT 30.3
12/03 NA 134.42, K 3.80, AST 19.21, ALT 11.28, BUN 2.70, CREA 38.36, LDH 168.94
12/03 UA Y, SH, 7.5, 1.02, TRACE, NEG, 5-9, 10-15

12/7 URINE CS MORE THAN 3 ORG SEEN UNFIT FOR CS

FF UP STD WORKUP RESULT
GABAYNE JUDITH 1290751 12/06/2019 26 DR DEMESA/ YELLOW G3P2 (2002)PU 35W 1 HYDROCORTISONE 250MG HR:
BP: RR: TEMP: 36- O2:
MAHINAY CHACON AOG BY LMP TIV AS LD THEN 100MG TIV VS 107-
100-120/60 22-24 36.9 95-98
10/02/1993 34W 6D Q8 120
T/C CAP MR ON TOP 2 IPRATROPIUM NEB PRN I:2000
OF BAIAE MILD FOR DOB O: 1500
INTERMITTENT 3 PRENATAL MVT TAB OD FHT120- 140S
4 FESO4 TAB OD
GH CONTROLLED 5 AZITHROMYCIN 500MG TAB 12/07 PT 13.9 INR 1.06 PTT 29.5
OD X 3 DAYS 12/07 NA 138.30 K3.19 AST 24.85 ALT 17.93 BUN 1.21 CREA 34.43 LDH 179.52
R/O GRAVIDOCARDIA 6 CEFTRIAXONE 2G TIV Q OD 12/07 CBC 128, 0.39, 12.7, 273
12/07 FT4 2.79 FT3 0.72 TSH 0.07
12/06 136.97 K 3.28 AST 24.49 ALT 19.64 BUN 1.09 CREA 33.29 LDH 166.35
12/06 24H URINE PROTEIN 27
12/06 CBC 135, 0.39, 8.8, 301

12/07 AWAITING PULMO NOTES

FF UP SPUTUM GS CS FOR CXR WITH ABDOMINAL SHIELD
FOR BPS ON MONDAY
NST OD
BALILI, DANICA 1323481 12/07/2019 19 DR DEMESA YELLOW G1P0 PU 13W AOG BY 1 PRENATAL MVT OD 1 BP: HR: RR: TEMP: O2:
VS
VALDEZ CHUA UTZ NIL 2 FESO4 TAB OD 100/60 82-107 22-29 36.5-36.7 91-98
3 SALBUTAMOL + IPRA NEB I:1000
09/08/2000 BAIAE PRN O:700
4 HYDROCORTISONE 100MG
6PM (+) DOB (+) T/C CAP MR TIV Q 6 12/07 CBC 119, 0.35, 14.3. 573
WHEEZING
O2SAT 91% HYDROCORTISONE 250 MG 12/07 AWAITING PULMO NOTES
WAS GIVEN SALBU TIV LD GIVEN

4
 + IPRA NEB
O2 SAT 95% AFTER
NEB

ROOM C
NAME | DOB HOSPITAL DATE OF AGE CONSULTANT | TEAM DIAGNOSIS MEDICATIONS HOSPITAL ORDERS
NUMBER ADMISSION RESIDENT DAYS
DIAZ, LINDA 1319848 11/18/19 63 DR. DE GYNE- CLEAR CELL 1. TRANEXAMIC ACID 500MG 11 HR:
CABIOC MESA/LOPEZ ONCO CARCINOMA OF TAB Q 8 BP: RR: TEMP: O2:
VS 101-
UTERUS, STAGE IIIB 2TRAMADOL 50MG TIV PRN 90-110/60-70 26-32 36.1-37 100
115
12/02/1955 3. PARACETAMOL 300MG TIV I:
Q4 (>38.4) O:
ACUTE 4. FESO4 TAB BID GCS 12 E4V2M6
RESPIRATORY 5. HRZE 3 TABS ODAC
DNI FAILURE SEC TO HAP 6. PIPTAZ 4.5 GM TIV Q 6 – D7 CBG: 8 AM 267 12PM 218 4PM 137 8PM 133
ON TOP OF PTB 7.OPTIMUM BOOST 7
SCOOPS + 1 GLASS H20 TID LABS:.
COMPLICATED UTI 8. HUMAN ALBUMIN 20% SIVP 12/4 AST 25.88 ALT 10.08
X 20 MINUTES 12/4 TOTAL NIL 107.08 DIRECT BIL 89.49 INDIRECT BIL 17.59
9. TRANEXAMIC ACID 1 GRAM
TIV Q 8 PRN 12/1 PT 15.4 INR 1.17 APTT 35.3
10. VITAMIN K 1 AMP TIV Q 8 11/29 CBC 108/ 0.31/ 19.3/ 347
X 3 DOSES - COMPLETED 11/27 24.1 / PT % ACT 43 / PT INR 1.85 / APTT 37.8
11. TRAMADOL + 11/26 CBC 81 / 0.24 / 16.1 / 341
PARACETAMOL TAB Q 8 11/26 ALBUMIN 17.38
12. ERTAPENEM 1 TIV OD 11/23 K 3.60
13. CELECOXIB 200 MG CAP 11/23 UA DARK YELLOW| SL.TURBID| 7 | 1.005| NEG | NEG | 10-15| 0-2
BID 11/22 K 2.71
14. IPATROPIUM NEB PRN 11/19 CBC 95, 0.28, 319, WBC 15.5, NEUTRO 0.86, LYMPHO 0.07
FOR DOB Q6 11/18 UA DARK YELLOW| SL.TURBID| 6.5| 1.02| 2+| TRACE| 4-6| TNTC
15. FUROSEMIDE 20MG POST 11/18 CBC 81.0 | 0.25| 16.9 | 450
ALBUMIN- GIVEN 11/18 NA 135.09| K3.00 | SGOT 27.33 | SGPT 15.22| BUN 1.58|CREA 28.69
11/18 PT 18.1 | PERCENT ACT. 63| INR 1.38 | NORMAL CONTROL 13.2 | APTT 33.6| 28.5

BLOOD CS, R AND L ARM (12/1)

NO GROWTH AFTER 5 DAYS OF INCUBATION

SPUTUM GS (11/27)
EPITHELIAL CELLS: 6-10 LPF
WBC: 2-3 LPF

SPUTUM BACTERIAL MORPHOLOGY (11/27)

GRAM NEGATIVE BACILLI – FEW
GRAM POSITIVE COCCI IN PAIRS - OCCASIONAL

URINE CS (11/23):
SELECTED ORGANISM: E. COLI
SENSITIVE RESISTANT
CEFEPIME CEFOXITIN
ERTAPENEM AMPICILLIN
PIPTAZO AMOX/CLAVULANIC
AMIKACIN CIPROFLOXACIN
CEFTAZIDIME
TRIMET+SULFA
IMIPENEM
MEROPENEM
GENTAMICIN

CXR:
SUSPICIOUS OPACITIES BOTH LUNG APICES

TB GENE XPERT 11/19: MTB NOT DETECTED

TVS AND TRANSVAGINAL UTZ

BULKY CERVIX AS DESCRIBED CONSIDER CERVICAL PATHOLOGY
ENLARGED RETROVERTED UTERUS
ILL;’DEFINED ENDOMETRIUM WITH INTRA ENDOMETRIAL CONTENTS AS DESCRIBED
CONSIDER ENDOMETRIAL PATHOLOGY POSSIBLE NON-BENIGN NATURE AND
EXTENSION TO THE CERVIX
CYSTIC MASS RIGHT AS DESCRIBED PROBABLY OVARIAN IN ORIGIN

5
 NO NORMAL OVARIAN TISSUES SEEN
ENCYSTED FLUID AS MEASURED

12/7 REFER BACK TO PULMO

INCREASE FIO2 TO 100%
CONT CBG MONITORING Q4

ROOM D
NAME | DOB HOSPITAL DATE OF AGE CONSULTANT | TEAM DIAGNOSIS MEDICATIONS HOSPITAL ORDERS
NUMBER ADMISSION RESIDENT DAYS
BESMONTE, 1321940 11/30/2019 32 DR POTIAN/ YELLOW G2P2 (2002) PUFT 1. CO AMOXICLAV 625MG/TAB 9 BP: HR: RR: TEMP: O2:
VS
JENNILYN MADRASO CEPHALIC DEL TO A 1 TAB BID 140-170/90-100 83-100 16-22 36-36.8 97-98
BALTAR LIVE BABY BOY AS 2. FESO4 TAB OD I:2600
7,8 VIA LTCS I FOR 3. ASCORBIC ACID TAB OD O:2300
09/26/1987 UNCONTROLLED 4. PARACETAMOL +
HYPERTENSION TRAMADOL Q8 LABS:
ADMITTING BP 5. NIFEDIPINE 30GITS ODHS 12/7 CBC 106, 0.32, 9.0 200
200/100 PES WITH SEVERE 6. CLONIDINE 75MG SL FOR 12/07 AST 85.81 ALT 68.38
FEATURES BP >/= 160/90 12/06 CBC 103.0/ 0.30/ 8.3/ 164
7. FUROSEMIDE 20MG/TB X 3 12/06 AST 87.30, ALT 62.91
HELLP DAYS OD – COMLETED 12/05 DENGUE IGG NEG/ IGM NEG/ NS1 POS
12/05 HBSAG
DENGUE FEVER MGSO4 DRIP COMPLETED 12/05 NA 153.32 K 9.11 CL 107.59 AST 98.18 ALT 62.65 ALK PHOS 106.27 BUN 6.33 CREA
WITHOUT WARNING 82.58 TOTAL BILI 12.52 DIR BILI 2.51 INDIRECT BILI 10.31 LIP 121.26 AMY 59.35 LDH
SIGNS 758.07
12/04 CBC 122, 0.36, 11.8, 77
12/04 NA 135.68, K 3.77, CL 107.44, AST 92.86, ALT 46.31, BUN 7.16, CREA 92.64, LDH
916.06
12/02 NA 132.43/K 4.20/ CL 109.44,
12/02 AST 58.18,ALT 58.18, AST 23.59, BUN 9.07, CREA 133.31, LDH 721.47
12/02 CBC 131,0.39,19.3,118
12/01 NA 134.46/ K 3.80, CL 108.99, AST 73.42, ALT 33.97, BUN 7.36, CREA 97.84
11/30 NA 134.03 K 3.71, AST 86.84, ALT 39.54, BUN 6.36, CREA 74.22, LDH 857.76
11/30 PT 12 INR 091 PTT 29.8
11/30 CBC 147, 0.42, 15, 139
11/30 YELLOW/ SL TURBID/ 7/1.01/ 3+ / NEG/ 0-2/ 2-4F

12/3 ECG: SINUS TACHY, POOR R WAVE PROGRESSION

12/07 HBT UTZ MILD HEPATOSPENOMEGALY , NORMAL GALL BLADDER & BILIARY
TREE

12/07 SERIAL CBC PC, SERIAL AST ALT

AWAITING IM CARDIO NOTES
12/07 OB IDS CONT MGT
CUNANAN, 1323241 12/03/2019 18 DR PERALTA/ BLUE G1P1 (1001) PU 1. HYDRALAZINE 5MG TIV Q20 5 BP: HR: RR: TEMP: O2:
VS
CANDIE MAE ROASA PRETERM MINS FOR BP >160/90 20 140/70-90 94-102 16-32 36.4-37.4 95-98
DELIVERED MINS MAX OF 4 DOSES I:2100
05/18/ 2001 CEPHALIC TO A LIVE 2.CO-AMOXICLAV 635MG/TB O: 1800
BABY GIRL TWIN A, BID
ADMITTING BP: PU PRETERM 3.FESO4 TAB OD LABS:
130/100 DELIVERED 4.ASCORBIC ACID TAB OD 12/07 CBC 102, 0.32, 16.6. 262
CEPHALIC TO A LIVE 5.NIFEDIPINE 30 GITS TAB 12/07 K 3.66, AST 21.61, ALT 13.34, BUN 7.63, CREA 111.13, LDH 419.63
BABY GIRL TWIN B ODHS 12/05 NA 138.9 K 3.75 AST 34.97 ALT 10.49 BUN 8.63 CREA 231.52 LDH 471.19
(+) DOB VIA LTCS 1 FOR 6.PARACETAMOL + TRAMADOL 112/05 CBC 98/ 0.31/ 20.1/176
(+) WHEEZING MALPRESENTED TAB Q8 12/04 CBC 96,0.30, 22.1, 155
TWIN 7.FUROSEMIDE 20MG/TIC 12/4 CREA 254.72
8.METOPROLOL 50MG TAB OD 12/3 CBC 90/ 0.29/ 19.2/ 175
PES IN AM 12/3 PT 13.6/ APTT 31/5
12/3 NA 136.76/ K 4/ AST 42.88/ ALT 26.73/ BUN 4.10/ CREA 172.12/ LDH 335. 09
S/P 1 U PRBC (12/3) 12/3 AB+
12/3 UA Y/C/5/1.03/+3/TR/15-20/20-30

12/04 CXR BILATERAL PULMONARY CONGESTION MAGNIFIED CARDIAC SILHOUETTE

12/07 T/S METOPROLOL 50MG TAB OD IN AM

AGRAVANTE 1323953 12/03/2019 44 DR SORIANO JOSE/ YELLOW G11P10 (10-0-1-10) 1 CO-AMOXICLAV 635MG/TB 5 BP: HR: RR: TEMP: O2:
VS
GINA RAMOS PU DEL TERM BID 120-150/70-90 78-103 17-21 36.1-36.5 95-99
04/15/1975 CEPHALIC TO BABY 2 FESO4 TAB OD I: 3000
GIRL AS 9 VIA LTCS 3 ASCORBIC ACID TAB OD

6
ADMITTING BP: I+ BTL FOR 4 KETOROLAC 30MG TIV X S O:1750
140/90 UNCONTROLLED DOSES – COMPLETED
HPN PES 5 PARACETAMOL + 12/3 CBC 119, 0.36, 13.8, 361
TRAMADOL TAB PRN 12/03 NA 137.62, K 3.84, CL 103.93, AST 25.50, ALT 12.53, BUN 2.05, CREA45.78, LDH
PES FOR PAIN 197.69
12/03 PT 13.1 INR 0.99, PTT 31.4
PULMO 12/03 HBSAG REACTIVE ANTI HBE REACTIVE
CONGESTION 12/03 Y, ST, 7.5, 1.015, TRACE, NEG, 0-1, 1-3

12/07 MGH ONCE OB IDS CLEARED

12/07 FP FF UP ON 12/11/2019
NOROMBABA, 1323377 12/05/2019 20 DR. CABARCELA/ BLUE G2P2(2002) PUFT 1.CEFAZOLIN 2G ANST(-) 3 BP: HR: RR: TEMP: O2:
VS
CRUSMAY SORIANO CEPHALIC DEL TO PTOR – GIVEN 90-140/60-90 81-107 19-21 36.1-37.6 96-99
LIVE BABY BOY AS 2. TRANEXAMIC ACID 1G/ TIV I: 2200
05/15/1999 9,9 VIA LTCS SEC TO X 3 DOSES Q8 - DONE O: 1900
NRFS 3. CEFOXITIN 1G TIV Q8 (-)
ADMITTING BP: ANST 12/05 CBC 130, 0.40, 10.4, 324
110/70 GRADE 3 SIGMOID 4.METRONIDAZOLE 500MG 12/05 UA Y/C/7.5/1.01/NEG/NEG/0-1/0-1
INJURY TIV Q8 ANST X 3 DOSES
5. OMEPRAZOLE 40 MG OD DIET C/O SURGERY
6. TRAMADOL TAB Q8 PRN
CO-AMOXICLAV 635MG/TB 12/7 SURGERY SIPS OF CL, MEDS AS ORDERED, ENCOURAGE AMBULATION
BID
FESO4 TAB OD
ASCORBIC ACID TAB OD 12/7 START ORAL MEDS CO-AMOXICLAV 635MG/TB BID
CELECOXIB 200MG TAB Q12 FESO4 TAB OD, ASCORBIC ACID TAB OD
PRN

BAUTISTA, 1314553 12/06/2019 35 DR. MENDOZA/ YELLOW G1P0 PU 34W6D 1. PARACETAMOL 900 MG TIV 2 BP: HR: RR: TEMP: O2:
VS
ABEGAEL SANTOS AOG BY EUTZ Q8 X 3 DOSES 130-140/80-90 108-103 19-21 36.5-37.5 97-99
(8W5D) NIL 2. NALBUPHINE 10 MG TIV X 4 I: 2200
2/13/1984 DOSES O: 1800
PES 3. MGSO4 DRIP
4. NIFEDIPINE 60 GITTS OD LABS:
ELDERLY
12/06 CBC 141.0/ 0.42/ 10.7/ 154
PRMIGRAVID
12/06 PT 12.8, PTT 30.3
12/06 LDH 275.03
12/06 UA LY, C, 7, 1.005, 2+, NEG, 3-6, 2-4
12/06 NA 137.11, K 3.98, CL 107.46, AST 34.40, ALT 28.62, BUN 3.52, CREA 55.56

SISMAR, 1301250 12/06/2019 26 DR. DE VERA/ YELLOW G1P1 (1001) PU 4. OMEPRAZOLE 40 MG TI OD 1 BP: HR: RR: TEMP: O2:
MANILYN SANTOS CEPHALIC WHILE NPO VS
140-170/90-100 88-100 19-20 36.5 98
RAYOS DELIVERED TO A 5. MGS04 DRIP COMPLETED I: 3200
LIVE BABY BOY AS CO-AMOXICLAV 635MG/TB O: 1950
2/14/1993 9 VIA LTCS I FOR BID
UNCONTROLLED FESO4 TAB OD LABS:
ADMITTING BP: HYPERTENSION ASCORBIC ACID TAB OD
12/06 CBC 124.0/ 0.36/ 13.7/ 356
180/100 PARACETAMOL + TRAMADOL
12/06 PT 12.6, PTT 29.4
PES NIFEDIPINE 30 GITS
12/06 NA 135.65, K 3.45, CL 108.97, BUN 2.01, CREA 42.84, LDH 219.92
12/06 UA Y, H, 7, 1.015, 3+, NEG, 0-2, 2-4
BONA, 1323444 12/06/2019 21 DR POTIAN YELLOW G1P1 (1001) PU DEL 1 HYDRALAZINE 2 BP: HR: RR: TEMP: O2:
VS
MARICON GAN DEVERA/ SANTOS TERM CEPHALIC TO 5MG SIVP FOR 120-140/90 88-101 19-21 36.5 95-99
02/03/1998 A LIVE BABY GIRL BP >/= 160/100
AS 9 VIA LTCS I FOR I: 1400
ADMITTING BP ARREST IN O: 1200
160/100 CERVICAL CBG 12PM 144, 6PM 109, 10PM 124
DILATATION
12/06 HBA1C 6.29
OVERT DM 12/07 CBC 144, 0.43, 13.7, 256
12/07 DY, ST, 7, 1.025, 3+, NEG, 10-15, 50-60
12/07 NA 138.05, K 3.69, AST 19.22, ALT 13.76, BUN 2.25, CREA 43.41, LDH 206.56

12/07 FOR CBG TID +10PM

FOR CBC PC 24H POST OP
TABLANTE 711703 12/06/2019 31 DR POTIAN/ DR YELLOW G3P3 (3003) PU CLONIDINE 2 BP: HR: RR: TEMP: O2:
VS
ALANIE NAZ SANTOS TERM CEPHALIC 75MCG SL FOR 110-150/90-100 79-88 19-21 36.5-37.1 98
DEL VIA LTCS II + BP >/= 160/100 Q I:3200
06/17/1988 BTL TO A LIVE BABY 20 MIN MAX OF 3 O: 3000
GIRL AS 9 DOSES
PCS X 1 FOR

7
 MALPRESENTATION NIFEDIPINE 30MG 12/06 CBC 105, 0.31, 15.4, 358
(2011 QMMC) ODHS 12/06 NA 136.34, K 3.57, AST 18.53, ALT 19.20, BUN 2.67, CREA 43.22 LDH 169.14
CO-AMOXICLAV 635MG/TB 12/06 LY/ H/ 7/ 1.005/ NEG/ NEG/ 1-3/ 3-5
BID
FESO4 TAB OD
ASCORBIC ACID TAB OD
PARACETAMOL +
TRAMADOL
RUIZ JULIE ANN 1323443 12/06/2019 29 DR POTIAN/ YELLOW G3P3 (3003) PU GENTAMYCIN TIV 2 BP: HR: RR: TEMP: O2:
VS
GAJES SANTOS TERM CEPHALIC OD 110/60 66-78 19-20 36.5 98-99
DEL TO A LIVE I:2300
03/24/1990 BABY BOY AS 9 VIA O: 1900
LTCS FOR NRFS,
PROM CBG 11PM 115 6PM 118 10PM 142
GDM UNKNOWN
CONTROL 12/06 CBC 127, 0.38, 263, 13.8
12/06 LY/ H/ 7.5/ 1.01/ NEG/ NEG/ 0-2/ 2-4
12/06 HBA1C 5.41

VILLAROSA 1175289 12/06/2019 25 DR YELLOW G2P2 (2002) PU DEL CO-AMOXICLAV 635MG/TB 2 BP: HR: RR: TEMP: O2:
VS
SALMIA VALDEZ POTIAN/SANTOS TO A LIVE BABY BID 120/60 82 19 36 97
BOY AS 9 VIA LTCS FESO4 TAB OD I: 2200
10/30/1994 II, PCS X1 FOR ACD ASCORBIC ACID TAB OD O: 1800
(2018 QMMC) PARACETAMOL + TRAMADOL
CBG 12 PM 125 4 PM 112 8PM 115 12AM 115
GDM DIET
CONTROLLED 12/07 CBC 133/ 0.39/ 9.5/ 170
12/07 Y/C/ 7/1.01/ NEG/ NEG/ 0-3/ NONE

12/07 CBC PC 24H POST OP

LAURIO RIO 1307336 12/05/2019 28 DR MENDOZA/ ORANGE G1P1 (1001) PUFT CO-AMOXICLAV 635MG/TB 3 BP: HR: RR: TEMP: O2:
VS
OAS SANGALANG CEPHALIC DEL TO A BID 120/80 88-107 19 36.5-36.8 98
LIVE BABY BOY AS FESO4 TAB OD I: 3100
09/22/1991 9 VIA LTCS I FOR ASCORBIC ACID TAB OD O:01850
ACD CELECOXIB CAP Q 12 CBG 6PM 115, 10PM 110

GDM DIET 12/07 CBC 99/ 0.31/ 18.4/ 202

CONTROLLED 12/07 Y/ C/ 7.5/ 1.02/ TRACE/ NEG/ 3-5/ 1-3

1/07 GIVE IRON SUCROSE 2 AMPS IN 90CC PNSS VIA SOLUSET NOW FOR 30MIN
FOR REPEAT CBC PC

ROOM G
NAME | DOB HOSPITA DATE OF AGE CONSULTANT | RESIDENT TEAM DIAGNOSIS MEDICATIONS HOSPITAL ORDERS
L ADMISSION DAYS
NUMBER
YAGUEL, 570452 11/27/2019 35 DRS. CHUA/ GYNE G4P3 (3003) H MOLE CO-AMOXICLAV 625 12 BP: HR: RR: TEMP: O2:
VS
MARISSA DR. PEREA PREGNANCY AT 16W1D MG/TAB BID FOR 7 DAYS 100-110/60-80 69-87 18-2 36.2-36.7 97-99
DOROY AOG BY LMP; FESO4 TAB OD I: 1800
ASCORBIC ACID TAB OD O: 1200
11/1/1984 PTB – COMPLETED CELECOXIB 200 MG/TAB
TREATMENT PRN LABS:
(+) BM BISACODYL SUPP 12/2 PT 13.1/ PTT 27.4
(+) FLATUS S/P TAHBS WITH NAHCO3 TAB, 1 TAB OD 12/2 BTRH: O+
BILATERAL CLORHEXIDINE GARGLE 11/28 ABO O+
HYPOGASTRIC ARTERY BID 11/28 BHCG 97047.0
LIGATION (12/02/19) 11/28 UA Y / H / 6 / 1.025 / - / - / 0-2 / 12-15
MTX THERAPY 0.8CC X 5 11/27 CBC 130 / 0.39 / 8.1 / 208
S/P APPENDECTOMY DAYS – DAY3COMPLETED 11/27 NA 137.52 / K 4.13 / C 104.32 / SGOT 18.62 / SGPT 23.44 / ALK PHOS 55.22 / BUN
2.74 / CREA 46.04 / CA 2.43 / MG 0.78 / PHOS 1.68

CXR INITIAL (11-27-19)

SUBSEGMENTAL ATELECTASIS, RIGHT UPPER LOBE. SUSPICIOUS OPACITY RIGHT

8
 APEX. SUGGEST APICO-LORDOTIC VIEW

CXR INITIAL (11/28)

APICOLORDOTIC INITIALS: PTB, RIGHT UPPER LOBE

TVS AND TAS

11/28 TO CONSIDER COMPLETE MOLE; NO ADNEXAL MASS

IM-PULMO NOTES 11/29/2019

FOR SPUTUM AFB X2
SPUTUM GENE XPERT
SECURE OFFICIAL CXR RESULT

WAB CT SCAN WITH TRIPLE CONTRAST INITIAL (11/29)

ENLARGED UTERUS WITH CENTRAL HYPODENSITIES PLUS THICK ENHANCING
PERIPHERY MEASURING 8.2X9.1X12.1 CM LIKELY REPRESENTING THE KNOWN
MASS. NO INVASIONS OF OTHER STRUCTURES. NO METASTASIS

GTD NOTES 12/7

FOR MTX THERAPY DAY 3
REYES, 1284568 12/03/2019 46 DR. MENDOZA/ PEREA GYNE G4P3 (3013) CO-AMOXICLAV 625 5 BP: HR: RR: TEMP: O2:
VS
MERLIN PELVOABDOMINAL MG/TAB BID FOR 7 DAYS 120-140/70-100 80-91 19-20 36.2-37.3 96-99
MAUSISA MASS PROB. OVARIAN FESO4 TAB OD I: 1900
NEW GROWTH PROB. ASCORBIC ACID TAB OD O: 1450
10/09/1973 MALIGNANT; CELECOXIB 200 MG/TAB
PRN LABS:
S/P APPENDECTOMY 12/4 UA LIGHT YELLOW SLIGHTLY TURBID 6.0 1.015 NEG NEG 0-2 HPF 0-1 HPF
(2015, BICOL); 12/3 FBS 5.34 NA 138.71 K 4.05 CL 105.38 AST 31.87 ALT 34.38 BUN 6.28 CREA 68.39
12/3: CBC: 136.0/ 0.42/ 7.9/ 332
S/P TAHBSO (12/6) 12/3: PT 12.2, PTT 25.9
12/3: FBS 5.34, NA 138.71, K 4.05, CL 105.38, AST 31.87, ALT 34.38, BUN 6.28, CREA
OBESE I 68.39
7/1: CA 125: 67.00, CA 19-9: 1720, CEA: 1.95

PMGH
ESPINAS 1303662 12/04/2019 37 DRS/ APEPE/PACLIBAR YELLOW G0 MYOMA UTERI; CO-AMOXICLAV 625 4
MARIFI LUCILO ENDOMETRIOMA RIGHT MG/TAB BID FOR 7 DAYS BP: HR: RR: TEMP: O2:
VS
FESO4 TAB OD 100-110/70-80 69-107 20-21 36.3-36.9 98-100
12/5/1981 S/P MYOMECTOMY & CELECOXIB 200 MG/TAB I: 1800
OOPHOROCYSTECTOMY PRN O: 1200
, RIGHT WITH ETHENYL/ ESTRADIOL +
ADHESIOLYSIS AND LEMONORGESTREL LABS
ENTEROLYSIS (12/6) 12/6 CBC 125, 0.37, 16.1, 190
12/05 CBC: 142, 0.42, 7.5, 327
S/P 2 U PRBC (12/5) 12/05: PT 15.0, PTT 32.05, %ACT 82, INR 1.14, NC 13.2
12/05: NA 139.36, K 3.68, CL 105.18, BUN 1.86, CREA 50.98, ALT 16.66, AST 11.24
11/20 TYPE O POSITIVE

OROGAN 1156947 12/03/19 56 DRS. SORIANO YELLOW G3 P3 (3003) AUB L R/O TRANEXAMIC ACID 500 4 BP: HR: RR: TEMP: O2:
VS
EDEN LAUTA JOSE/RAMOS EM PATHOLOGY; MG TIV 100-110/60-80 75-95 18-20 36.1-37 98-99
ANEMIA SECONDARY ; FESO4 TAB OD I: 2300
03/25/1983 PCS BIL (1995. QCGH) CALCIUM GLUCONATE 1 O: 1100
DOSE
S/P 5 U OF PRBC (12/6) LABS
12/7 CBC 103 0.33 28.0 355
12/6 CBC 93, 0.30, 25.6, 333
12/5 URINE GS G(-) BACIILI FEW; G(+) COCCI FEW; EPITHELILA CELLS OCCASSIONAL;
WBC 1-21/OIO
12/5 CBC: 78, 0.26, 23.9, 289
12/3 CBC 43.0 0.16 15.4 459
12/3 PT 14.9 INR 1.13 APTT 28.8
12/3 NA 134.96 K 3.71 CL 103.47 AST 18.47 ALT 10.28 BUN 3.24 CREA 51.15 LDH 350.74
12/ 3 UA DARK YELLOW HAXY 6.0 1.015 TRACE NEG 0-1 HPF 2-5 HPF

12/6 KUB UTZ INITIAL

NORMAL SIZED KIDNEYS WITH MILD UTERO PELVICIECTASIA. MINIMAL
PERIHEPATIC ASCITES. ENLARGED UTERUS WITH THICK HETEROGENOUS WALLS.
URINARY BLADDER WITH IREEGULAR THICKENED WALLS, CONSIDER CYSTITIS.
SUGGEST CORRELATION WITH TVS

12/5 TVS:

9
 CONSIDER EM PATHOLOGY, PROBABLY MALIGNANCY
DISTENDED CERVIX PROBABLY EM PATHOLOGY EXTENSION
BOTH OVARIES SONOGRAPHICALLY ABSENT

AWAITS IMCP
RINONOS 1310600 12/04/2019 60 DRS. MORALES YELLOW G3 P2 (2012) CO-AMOXICLAV 625 4 BP: HR: RR: TEMP: O2:
VS
ADELA DE /PACLIBAR ENDOMETRIAL MG/TAB BID 100-110/60-80 74-86 19-21 36.1-36.5 95-99
LEON CARCINOMA, S/P CELECOXIB 200 MG/CAP I: 1600
ENDOMETRIAL PRN O: 1100
01/07/1959 CURETTAGE AND FESO4 OD
POLYPECTOMY (OCT LABS
2019) HTN 12/5 TYPE O POSITIVE
11/06 CBC 127 0.38 8.5 211
S/P EHBSO (12/6) 11/06 NA 140.02 K 3.72 CL 105.35 AST 25.56 ALT 17.74 BUN 3.02 CREA 66.02
11/18 FBS 5.02
11/18 PT 12.2 INR 0.93 APTT 28.7

ECG NSR

11/13 WAB WITH CONTRAST

DIFFUSELY ENLARGED RETRVERTED UTERUS WITH AN IRREGULARLY SHAPED,
HETEROGENEOUSLY ENHANCING HYPO TO ISODENSE MASS WITH INTRALESIONAL
CALCIFICATIONS. FINDING LIKELY REPRESENTS CLINICALLY KNOWN MALIGNANCY
HYPODENSE FOCUS IN THE ANTERO SUPERIOR SEGEMNT OF THE RIGHT HEPATIC
LOBE, PROB A SIMPLE CYST.
ATHEROSCLEROTIC AORTA AND BILATERAL INTERNAL CAROTID ARTERIES
DEGENERATIVE OSSEOS CHANGE, THORACOLUMBAR SPINE

SAMONTANES 1316079 12/04/2019 37 DR YELLOW G0 MYOMA UTERI CO-AMOXICLAV 625 3 BP: HR: RR: TEMP: O2:
VS
SUSAN APEPE/DAMALERIO RIMARY INFERTILITY MG/TAB BID 110-120/60-80 74-90 18-22 36.4-37.7 96-99
OROCIO FOR 10 YRS-MALE CELECOXIB 200 MG/CAP I: 1700
FACTOR, UTERINE PRN O: 1300
6/26/1982 FACTOR, POOR ASCORBIC ACID OD
OVARIAN RESERVE FESO4 OD LABS
TRANEXAMIC ACID 500MG 12/6 CBC 99, 0.31, 17.6, 212
S/P MYOMECTOMY WITH TIV Q8 12/5 TYPE A POSITIVE
CHROMOTUBATION 12/2 PT 14.4 INR 1.09 APTT 33.4
(12/5) 12/2 CBC 6119 0.37 8.8 367
12/2 NA 139.33 K 3.99 CL 104.58 AST 46.31 ALT 66.71 BUN 3.72 CREA 54.84
S/P 2 U PRBC (12/5) 12/2 UA YELLOW SLIGHTLY TURBID 5.5 1.03 NEG NEG 1-3 HPF 0-1 HPF

DP
CAUNCA 1227428 12/04/19 50 DRS. BANAL/SISON GYNE G7 P7 7007 MYOMA CO-AMOXICLAV 625 4 BP: HR: RR: TEMP: O2:
VS
YOLEMIA ONCO UTERI, MG/TAB BID 130-140/80-90 78-91 19-20 36.2-37 97-99
SARMIENTO CELECOXIB 200 MG/CAP I: 1500
HTN STAGE 1 PRN O: 1200
01/07/1959 ASCORBIC ACID OD
S/P TAHBSO (12/6/19) FESO4 OD LABS
12/6 CBC 86, 0.27, 21, 416
S/P 1 U PRBC (12/5) 12/5 TYPE O POSITIVE
12/4 PT 14.3 INR 1.08 APTT 31.6
12/4 CBC 122 0.38 16.1 492
12/4 NA 139.64 K 4.41 CL 54.54 BUA 333.40

TRANSABDOMINAL UTZ 10/11

ENLARGED ANTEVERTED UTERUS
ENDOMETRIUM CONSISTENT WITH PROLIFERATIVE PHASE
HUGE POSTERIOR MYOMA NODULE FIGO 5
CYSTIC LEFT OVARY, PROBBALY PHYSIOLOGIC CYST
RIGHT OVARY NOT VISUALIZED
LLANEB, 1323998 12/04/19 32 DRS. VERGARA/SISON ORANGE G1PO (0010) TUBAL CO-AMOXICLAV 625 2 BP: HR: RR: TEMP: O2:
VS
ELEONITA PREGNANCY 6W3D MG/TAB BID 90-110/60-80 91-100 19-21 36.1-37.1 97-99
ASILO AOAG BY LMP, CELECOXIB 200 MG/CAP I: 2000
AMPULLARY, LEFT, PRN O: 1400
09/28/1987 RUPTURED ASCORBIC ACID OD
FESO4 OD LABS:
S/P EXLAP, RIGHT 12/4 CBC: 116. 0.34, 17.4, 341
SALPINGECTOMY (12/4) 12/4: NA 138.41, K 3.226, AST 22.72, ALT 17.24, BUN 3.81, CREA 48.53, LDH 160.81
12/4: PT 14.5, PTT 22.7, %ACT 87, INR 1.10, NC 13.2
MORRE 1324225 12/06/2019 26 DR POTIAN/SANTOS YELLOW G2P1 (1001) T/C FESO4 OD 2 VS BP: HR: RR: TEMP: O2:
MARY JANE ECTOPIC PREGNANCY

10
 ABINDAN AT 6W 4D AOG BY LMP, 120/70 80 19 36.5 97
PROB UNRUPTURED I: 1400
01/27/1993 O: 1050

LABS:
12/6 CBC 119, 0.35, 5.9, 150
12/6 BHCG 329.70
12/6 CBC 129, 0.38, 5.8, 264

OB NOTES 12/7
CBC PC OD
BHCG TODAY AT 7PM

YARANON, 1311007 12/04/2019 48 DR VERACRUZ/SISON GYNE G7P7 (7007) OVARIAN CO-AMOXICLAV 625 4 BP: HR: RR: TEMP: O2:
VS
NITA CRUZ ONCO NEW GROWTH PROB MG/TAB BID 90-110/60-80 64-81 18-20 36.2-36.8 95-99
MALIGNANT CELECOXIB 200 MG/CAP I: 1600
02/17/1971 INTRAOPERATIVE PRN O: 1400
STAGE IIB ASCORBIC ACID OD
FESO4 OD LABS:
S/P TAHBSO WITH BLND BISACODYL 12/5 CT 1 MIN, BT 3 MIN
(12/5) SUPPOSITORY ODHS 12/5 CBC 100, 0.31, 10, 287
12/5 PT 15.5, APTT 28.3
S/P 2 U PRBC (12/5) 12/5 ABO TYPE O+
12/4 PT 15.7, APTT 28
12/4 NA 135.58, K 4.15, CL 105.05, AST 31.60, ALT 15.76, BUN 4.31, CREA 70.50
12/4 CBC 109, 0.34, 6.7, 473

REGALA, 1265388 12/05/2019 24 DR CABANELA/ SORIANO BLUE G4P3 (2032) TUBAL CO-AMOXICLAV 625 3 BP: HR: RR: TEMP: O2:
VS
ROSEMARIE PREGNANCY AT 5W AOG MG/TAB BID 90-100/60-80 90-100 20-21 36.2-37.2 97-99
BANAGUA BY LMP, AMPULLARY CELECOXIB 200 MG/CAP I: 900
RUPTURED PRN O: 1100
10/27/1995 S/P EXLAP ASCORBIC ACID OD
SALPINGECTOMY, LEFT FESO4 OD LABS:
FOR ECTOPIC BISACODYL 12/6 CBC 109, 0.32, 10.3, 320
PREGNANCY (2019, SUPPOSITORY ODHS 12/5 CBC 128, 0.37, 14.7, 401
QMMC) 12/5 PT 13.4, APTT 24.8
12/5 NA 138,83, K 4.30, AST 22.75, ALT 14.69, BUN 2.96, CREA 42.48, LDH 310,29
S/P RIGHT 12/5 ABO TYPE A+
SALPINGECTOMY (12/5)
DP
S/P 1 U PRBC (12/5)
ARENGA, GINA 1230225 12/05/2019 49 DR CABANELA/ SORIANO BLUE G3P3 FESO4 TAB BID 3 BP: HR: RR: TEMP: O2:
VS
PRIETO (3003PERIMENOPAUSAL 110-120/70-80 80-96 19-20 36.3-36.9 98-99
BLEEDING R/O EM I: 1550
02/20/1970 PATHOLOGY, ANEMIA O: 1150
SECONDARY
LABS:
S/P 3 U PRBC (12/7) 12/6 ABO TYPE B+
12/6 PT 15.6, APTT 30.1
12/6 NA 138.70, K 4.11, CL 106.15, AST 14.42, ALT 9.54, BUN 3.52, CREA 58.34
12/6 CBC 69, 0.23, 18.2, 592
12/5 CBC 74, 0.24, 22.9, 566
12/5 UA Y, ST, 6, 1.01, NEG, NEG, 25-30, 40-50

12/6 TVS
SLIGHTLY ENLARGED ANTEVERTED UTERUS WITH ADENOMYOSIS, POSTERIOR
MYOMA. SLIGHTLY THICK ENDOMETERIUM CONSIDER ENDOMETRIAL PATHOLOGY.
NORMAL LEFT OVARY AND RIGHT OVARY NOT VISUALIZED

12/6 ECG SINUS RHYTHM

IM NOTES 12/7
FACILITATE ANEMIA CORRECTION

OB NOTES 12/07
SECUR AND TRANSFUSE 2 U PRBC

ZIPAGAN, 1324117 12/05/2019 40 DR CABANELA/ SORIANO BLUE G0 ONG PROB CELECOXIB 200 MG CAP 3 BP: HR: RR: TEMP: O2:
VS
NIEVA RESCO MALIGNANT, MASSIVE 100-110/60 108-118 19-20 35.6-36.1 97-99
ASCITES I: 2450

11
 05/10/1979 S/P O: 1500
CHOLECYSTECTOMY
LABS:
12/5 CA 19-9 14.90
12/5 CA 125 4170 (H)
12/5 CBC 111, 0.35, 9.6, 686
12/5 NA 135.84, K 4.22, AST 20.63, ALT 12.02, BUN 3.04, CREA 50.43
12/5 UA Y, ST, TR, NEG, 4-8, 5-10

12/6 TVS
NORMAL SIZED ANTEVERTED UTERUS, THIN INTACT ENDOMETRIUM,
ABDOMINOPELVIC MASS CONSIDER OVARIAN NEW GROWTH, CANNOT TOTALLY
RULE OUT MALIGNANCY
CYSTIC LECT OVARY, CONSIDER PHYSIOLOGIC CYST
SONOGRAPHIC FINSINGS CONSISTENT WITH AP KOCH’S

12/6 ECG SINUS TACHYCARDIA

OB NOTES 12/7
FOR WAB UTZ ON 12/9/19 8 AM
FF UP CXR RESULT

TIENGO 1323452 12/06/2019 21 DR POTAIN DE VERA/ YELLOW G0 AUB-O; TRANEXAMIC ACID 1G 2 BP: HR: RR: TEMP: O2:
VS
ALEXANDRA SANTOS ANEMIA SECONDARY; TAB TID 90-100/60-80 90-100 20-21 36.2-37.2 97-99
ROAMAR T/C ONG PROB BENIGN, FESO4 TAB OD I: 2400
LEFT O: 1300
02/27/1998
LABS:
12/07 UA YELLOW SLIGHTLY TURBID 6.5 1.005 NEG NEG 12-14 HPF 55-65 HPF
12/7 PT 15.2 INR 1.15 APTT 28.7
12/6 CBC 74, 0.24, 8.6, 504

SECURE 2 U PRBC
BERBOSO 1316386 12/07/2019 48 DRS. PUNZALAN/PEREA ORANGE G3 P3 3003 AAUB- TRANEXAMIC ACID 500 1 BP:
HR: RR: TEMP: O2:
MARIA ANNA LEIOMYOMA, MG IV Q8 VS 140/90
110 20-21 36.2-37.2 97-99
GUIAO SUBMUUCUOS, METRONIDAZOLE 500 MG
PROLAPSED TAB TID FOR 3 DAYS- DAY I 800
05/17/1981 2 O 650
HYPERTENSION STAGE CEFOXITIN 2 G IV
II LABS
11/21 PT 1300 INR 0.99 APTT 30.4
11/8 CBC 89.0 0.32 12.5 226

SECURE 2 UNITS OF PRBC

MORALES 1295644 12/07/2019 70 DR. SORIANO JOSE YELLOW G5 P2 2031 POP STAGE IRBESARTAN 150MG TAB 1 BP: HR:
RR: TEMP: O2:
RUFINA IV S/P PARTIAL OD VS 110/80 85-91
20-21 36.4-37.1 97-99
ILAGAN THYROIDECTOMY; PCS ATORVASTATIN 40 MG
X 1 (1987) TAB ODHS
08/31/1949 I 800
O 450

LABS
11/18 TOTAL CHOLE 5.65 HDL 1.72 LDL 3.38 TRI 1.20 NA 143.51 K 4.55 CL 106.78AST
27.82 ALT 15.74 BUN 6.77 CREA 58.42

OB NOTES 12/07
FOR VAGINAL HYSTERECTOMY WITH AP REPAIR ON MONDAY DEC 9 AT 10 AM
SECURE 2 U PRBC
ABORDO 1323497 12/07/2019 35 DRS.PUNZALAN/BELOCUR ORANGE G2 P1 1001 T/C TRANEXAMIC ACID 500 1 BP: HR: RR: TEMP: O2:
VS
MARY GRACE A RETAINED SECUNDINES MG CAP TIV Q8 100-120/80-90 70-89 20-21 36.2-37.2 97-99
FULE S/P COMPLETION FERROUS SULFATE TAB
CURETTAGE (11/27/2019, OD I 1000
01/19/1984 SAN PABLO LAGUNA O 900
HOSPITAL) MYOMA
UTERI
LABS
12/7 UA YELLOW CLEAR 7.0 1.01 NEG NEG 1-2 HPF 0-2 HPF
12/7 BHCG 467.23
12/7 CBC 105 0.32 9.3 315

12
 OB NOTES 12/07
WOF FOR PROFUSE BLEEDING, PASSAGE OF BLOOD CLOTS AND MEATY
MATERIAL

ROOM K
NAME | DOB HOSPITA DATE OF AGE CONSULTANT | RESIDENT TEAM DIAGNOSIS MEDICATIONS HOSPITA ORDERS
L ADMISSIO L DAYS
NUMBER N
TUBALINAL, 1324029 12/03/2019 26 DR. CHUA/ SISON ORANGE G1P0 (0010) T/C METHOTREXATE 0.8 CC IM 5 BP: HR: RR: TEMP: O2:
VS
JEMABELLE GESTATIONAL X 5 DAYS – DAY 2 90-110/60-70 75-90 19-21 36.5-36.9 97-98
TAULE TROPHOBLASTIC NAHCO3 TAB TID I: 1300
NEOPLASIA STAGE I CHLORHEXIDINE GARGLE O: 1000
7/18/1993 TID
S/P ENDOMETRIAL CHLORHEXIDINE GARGLE
CURETTAGE (JULY TID LABS
2019, LAGUNA) 12/4 UA YELLOW TURBID 7.5 1.01 NEGATIVE NEGATIVE 2-1 HPF
12/4 BHCG 69334.00
12/3 ABO TYPE O POSITIVE
12/3 CBC 145 0.42 9.8 359
12/3 NA 137.64 K 3.88 AST 19384 ALT 11.05 BUN 1.94 CREA 43.76
12/3 PT 13.9, APTT 27.3

7/11/19 TVS:
SLIGHTLY ENLARGED ANTEVERTED UTERUS
INTRA ENDOMETRIAL CONTENTS AS DESCRIBED SUGGESTIVE OF MOLAR
GESTATION
NORMAL OVARIES

7/18/19 TVS:
ENLARGED ANTEVERTED UTERUS
ENDOMETRIAL MASS, GESTATIONAL TROPHOBLASTIC NEOPLASIA IS HIGHLY
CONSIDERED
CYSTIC STRUCTURE, LEFT OVARY, SUGGESTIVE OF CYSTIC FOLLICLE
NORMAL RIGHT OVARY

8/14/19 TVS:
ENLARGED ANTEVERTED UTERUS
MOLAR PREGNANCY T/C GESTATIONAL TROPHOBLASTIC NEOPLASIA, AN INVASIVE
MOLE HIGHLY CONSIDERED
BILATERAL THECA LUTEIN CYSTS

12/5 WAB CT SCAN

GLOBULARLY ENLARGED ANTEVERTED UTERUS WITH ENHANCINGNODULAR AND
LINEAR DENSITIES WITHIN THE ENDOMETRIALCAVITY, ADJACENT MYOMETRIUM
SUGGESTIVE OF MOLAR PREGNANCY
BONE ISLAND, RIGH TFEMORAL HEAD

12/5 TVS
CANNOT TOTALLY RULE OUT GESTATIONAL TROPHOBLASTIC NEOPLASIA

12/6 CXR INITIAL

NEGATIVE CHEST FINDINGS

12/6 ECG SINUS TACHYCARDIA

7/12/19 BHCG: 8,150

7/19/19 BHCG: 1000
8/05/19 BHCG: 5000
QUILANTANG, 1323398 12/05/2019 54 DR CABANELA/ SORIANO BLUE G5P5 (5005) FESO4 + FOLIC ACID TAB 3 BP: HR: RR: TEMP: O2:
JAMELJIA SQUAMOTRANSITIONA TID VS
90-100//60-90 90-97 19-22 36.3-36.9 98-100
LORENTE L CA STAGE IIIB AKI TRAMADOL+PARACETAMOL I: 2800
SEC TO OBSTRUCTIVE TAB Q8 PRN O: 1200
11/09/1965 UROPATHY; SEVELAMER 80MG/TB TID
ANEMIA SECONDARY LACTULOSE 30CC ODHS LABS:
12/7 TYPE O POSITIVE
12/6 ALB 21.34 CA 2.92 MG 0.93 PHOS 1.76
12/6 UA Y, S TURBID, 6, 1.005, +1, NEG, 50-60, 2-4
12/6 ALB 21.34, CA 2.92, MG 0.93, P 1.76
12/5 CBC 77, 0.24, 22.6, 542

13
 12/5 AST 14.75, ALT 11.79, BUN 14.14, CREA 370.28, NA 130.75, K 5.86, CL 105.41
12/5 ABG 7.51, 22.5, 149.5, 18.5, -1.8, 99.6

12/6 ECG SINUS TACHYCARDIA

12/5 TVS
WITHIN THE ENDOMETRIAL CAVITY IS AN ECHOGENIC STRUCTURE WITH CYSTIC
SPACES OF APPROX 5.58X4.59X5.93 CM CONSISTENT WITH MOLAR TISSUES.
CANNOT TOTALLY R/O GESTATIONAL TROPHOBLASTIC NEOPLASIA

IM NEPHRO 12/6
START EPO 4000 U SQ POST HD
ADVISED FOR HD

OB NOTES 12/6
TRANSFUSE 2 U PRBC
FOR WAB CT SCAN
FOR KUB UTZ ON 12/9/19 AT 11:30 AM
DELOS REYES 1105647 12/07/2019 61 DRS. GYNE SQUAMOUS CELL CA TRANEXAMIC ACID 500 MG 1 BP: HR: TEMP: O2:
VS
EDITHA MORALES/CABANELA/MUAR ONCO OF CERVIX CARGE CAP TIV Q6 110/80 81-85 36.7-37.1 97-100
CABAS O CELL NON TRAMADOL + I 1100
KERATINIZING STAGE II PARACETAMOL TAB Q8 O 750
07/16/1958 B G3 P3 (3003) FESO4 TAB OD
LABS
12/7 AST 20.38 ALT 16.09 BUN 6.27 CREA 143.09
12/7 PT 15.4 INR 1.17 APTT 22.8
12/7 CBC 70.0 0.26 10.4 389

GYNE NOTES 12/7

SECURE AND TRANSFUSE 2 U PRBC

ROOM M
NAME | DOB HOSPITAL DATE OF AGE CONSULTANT | TEAM DIAGNOSIS MEDICATIONS HOSPITA ORDERS
NUMBER ADMISSION RESIDENT L DAYS
ARBOLLENTE, 1303732 12/03/2019 44 DR. PERALTA/ BLUE G5P5 (5005) PU TERM NIFEDIPINE60 GTTS ODHS 5 BP: HR: RR: TEMP: O2:
VILMA ROASA CEPHALIC COAMOXICLAV 625 MG/TAB VS
110-180//70-110 80-99 18-19 36.7-37.2 97-100
FUENTEVILLA DELIVERED TO A LIVE BID X 7 DAYS I: 1100
BABY GIRL AS 9 VIA FESO4 TAB OD O: 850
7/13/1975 NSD; ASCORBIC ACID TAB OD
CELECOXIB 200 MG/TAB PRN LABS:
ADMITTING PES W/ SEVERE FUROSEMIDE 20MG TIV 12/3: CBC: 121.0/ 0.39/ 27.8/ 218
BP: 190/110 FEATURES ODHS 12/3: CBC: 106.0/ 0.35/ 12.8/ 224
METOPROLOL 50 MG TAB BID 12/3: PT 12.8, PTT 31.6
S/P BTL (12/5) CLONIDINE 75 MG TAB 12/3: NA 137.61, K 3.71, CL 113.69, AST 23.50, ALT 9.27, BUN 4.15, CREA 58.58,
LDH 369.43
12/3: UA SLIGHTLY RED, T, 7, 1.015, 3+, NEG, TNTC

12/3: 12-L ECG: SINUS TACHYCARDIA; NON ST TWC

IM CARDIO 12/7
START METOPROLOL 50 MG TAB BID
START CLONIDINE 75 MG TAB FOR BP > 160/90 MMHG
MONTES, 1323338 12/04/2019 36 DR. MENDOZA/ ORANGE G5P5 (6005) PU, TERM COAMOXICLAV 625 MG/TAB 4 BP: HR: RR: TEMP: O2:
MANSUETA SANGALANG CEPHALIC BID X 7 DAYS VS
130-150/100 88-107 18-24 36.4-37.1 97-99
VILLATO DELIVERED TO TWIN FESO4 TAB OD I: 2400
A LIIVE FRANK ASCORBIC ACID TAB OD O: 1900
07/05/1983 BREECH BABY BOY CELECOXIB 200 MG/TAB PRN
VIA PBE AS 9,9, TWIN NIFEDIPINE 60GITS ODHS LABS:
ADMITTING B CEPHALIC DEAD BETAMETHASONE VALEATE 12/5 UA LYELLOW, S HAZY, 6, 1.005, TR, NEG, 0-2. 4-8
BP: 130/80 BABY BOY CREAM MIX WITH 12/5 CBC: 148, 0.44, 10.4, 181
LOTION (1:1), APPLY TO 12/5: HBA1C: 5.06
PES WITH SEVERE AFFECTED AREA BID 12/5: NA 130.35, K 3.56, AST 24.51 , ALT 20.31, BUN 1.88, CREA 49.53, LDH 284.34
FEATURES 12/5: PT 12.8, %ACT 106, INR 0.97, NC 13.2, PTT 27.9

DERMA:
VASCULITIS
KALAW 685669 12/05/2019 24 DR. MENDOZA/ ORANGE G4P4 (4004) PU, COAMOXICLAV 625 MG/TAB 3 BP: HR: RR: TEMP: O2:
JELLYMER SANGALANG CEPHALIC, BID X 7 DAYS VS
80-110/60-90 73-108 19-20 36.0-37.2 97-99
LARGO DELIVERED TO A LIVE FESO4 TAB OD I: 1850
BABY BOY AS 9,9, VIA ASCORBIC ACID TAB OD O: 1200

14
12/25/1994 NSD CELECOXIB 200 MG/TAB PRN
METHIMAZOLE 5 MG 2 TABS LABS
NNTG OD 12/7 UA YELLOW SLIGHTLY TURBID 6.5 1.01 TRACE NEG 0-1 HPF 5-10 HPF
12/7 CBC 124 0.37 27.7 216
HYPERTHYROIDISM 12/7 FT3 4.43 FT4 1.14
NOT IN STORM 12/5 CBC: 124, 0.38, 10.2, 203
12/5: T4 11.30, T3 2.44, TSH <0.015
12/5 URINALYSIS: LIGHT YELLOW, SLIGHTLY HAZY, 7, 1.01, ALB 2+, SUG NEG, 1-2, 3-7

ENT NOTES 12/7

MGH ENT-WISE
FOR THYROID UTZ WITH TRADS AS OPD BASIS
BRING THYROID FUNCTION TEST RESULT AT ENT OPD
SERAFIN, 745990 12/5/2019 33 DR. CABANELA/ BLUE G6P6 (6005) PU, TERM COAMOXICLAV 625 MG/TAB 3 BP: HR: RR: TEMP: O2:
VS
JOAN SORIANO CEPHALIC, BID X 7 DAYS 100-130/80-90 77-94 16-21 36.7-37.2 97-99
DELMORO DELIVERED TO A LIVE FESO4 TAB OD I: 2400
BABY BOY, APGAR ASCORBIC ACID TAB OD O: 1200
05/25/1986 SCORE 9,9 VIA OFE CELECOXIB 200 MG/TAB PRN
CEFUROXIME 75MG TIV Q8 X LABS
ADMITTING S/P APPENDECTOMY 24 – DAY 2 12/7 110 0.33 10.0 247
BP: 130/90 (2017, AMANG) 12/5 CBC: 136.0, 0.40, 27.5, 311
MGSO4 DRIP COMPLETED 12/5: NA 136.80, K 3.56, AST 16.04, ALT 11.58, BUN 1.27, CREA 43.03, LDH 250.37
PREECLAMPSIA 12/5 URINALYSIS: YELLOW, CLEAR, 5.5, 1.03, ALB NEG, SUG NEG, NONE, 20-25
12/5: PT 13.9, %ACT 93, INR 1.05, NC 13.2, PTT 31.5

OB NOTES 12/7
FOR BTL ON MONDAY
GUERZON 1323478 12/07/2019 41 DRS. DEMESA/ YELLOW G5 P4 (4004) PU TERM COAMOXICLAV 625 MG/TAB 1 BP: HR: RR: TEMP: O2:
VS
CARISSA CHACON CEPHALIC BID X 7 DAYS 120-130/80-90 85-105 19-20 36-37.2 97-100
OCAMPO DELIVERED TO A LIVE FESO4 TAB OD I: 2000
BABY GIRL, AS 9 9 VIA ASCORBIC ACID TAB OD O: 1400
06/24/1978 NSD CELECOXIB 200 MG/TAB PRN
CBG: 116 189 200
ADMITTING OVERT DM UNKNOWN
BP CONTROL; LABS
150/100 12/7 LIGHT YELLOW HAZY 6.0 1.01 NEG 3+ 0-2 HPF 2-4 HPF
CH R/O SPE 12/7 HBA1C 8.02
12/7 CBC 130.0 0.39 8.2 150
12/7 NA 137.21 K 3.82 AST 14.84 ALT 10.41 BUN 3.04 CREA 48.50 LDH 156.06
12/7 PT 12.8 INR 0.97 APTT 28.8

OB NOTES 12/07
CBG PRE MEALS PLUS 10 PM

TEROL 1165829 12/07/2019 40 DRS. DEMESA/ YELLOW G5 P5 (5005) PU TERM COAMOXICLAV 625 MG/TAB 1 BP: HR: RR: TEMP: O2:
VS
MARLENE CHACON CEPHALIC TO A LIVE BID X 7 DAYS 110/80 83 16-19 36.5 97-99
COSCULLA BABY BOY AS 9 9 VIA FESO4 TAB OD I: 1800
NSD + REPAIR OF ASCORBIC ACID TAB OD O: 1100
07/18/1979 LACERATION UNDER CELECOXIB 200 MG/TAB PRN
LOCAL ANESTHESIA LABS
ADMITTING 12/7 UA YELLOW S TURBID 7.0 1.02 TRACE NEG 2-4 HPF 50-60 HPF
BP ASSISTED VAGINAL 12/7 NA 135.68 K 3.51 CL 107.59 AST 24.
130/90 DELIVERY 26 ALT 13.86 BUN 2.52 CREA 35.96
12/7 CBC 100 0.32 10.6 195
GH R/O PES 12/7 HBA1C 5.91
12/7 NA 136.69 K 3.56 ALB 33.07 AST 20.27 ALT 13.10 BUN 2.56 CRTEA 39.06 LDH
279.16

BARONIA 1323829 12/07/2019 24 DRS. CACAS/LOPEZ BLUE G1 P1 (1001) PU TERM COAMOXICLAV 625 MG/TAB 1 BP: HR: RR: TEMP: O2:
VS
MARIEL DELIVERED TO A BID X 7 DAYS 110-120/60-100 86-100 16-21 36.2-37.5 97-100
CABIT LIVEBABY BOY AS 9 9 FESO4 TAB OD I: 1650
VIA NSD ASCORBIC ACID TAB OD O: 1200
04/12/1995 CELECOXIB 200 MG/TAB PRN
ANTERIOR NECK LABS
MASS 12/7 UA YELLOW TURBID 7.0 1.01 NEG NEG 9-12 HPF 0-2 HPF
12/7 NA 137.49 K 3.73 AST 19.53 ALT 19.86 CREA 57.06 BUN 2.15
12/6 PT 12.5 INR 0.95 APTT 34.0

OB NOTES 12/07
REFER TO ENT

15
 CAJEDA 1077132 12/07/2019 31 DRS. PUNZALAN/ ORANGE G3 P3 (3003) PU TERM COAMOXICLAV 625 MG/TAB 1 BP: HR: RR: TEMP: O2:
VS
MARY ROSE BELOCURA CEPHALIC BID X 7 DAYS 140/90 88 17 36.0 97-100
MACATALAD DELIVERED TO A LIVE FESO4 TAB OD I: 1500
BABY BOY AS 9 9 VIA ASCORBIC ACID TAB OD O: 1300
04/07/1988 NSD CELECOXIB 200 MG/TAB PRN
LABS
ADMITTING GH T/O PES 12/7 CBC 135 0.42 14.3 245
BP 12/7 NA 137.91 K 3.07 AST 26.54CALT 16.71 BUN 1.24 CREA 26.95 LDH 241.51
140/90 12/7 PT 12.3 INR 0.93 APTT 26.5
12/7 UA YELLOW TURBID 7.0 1.02 1 = NEG 3-7 HPF 60-70 HPF

SICU
NAME | DOB HOSPITAL DATE OF AGE CONSULTANT | TEAM DIAGNOSIS MEDICATIONS HOSPITAL ORDERS
NUMBER ADMISSION RESIDENT DAYS
YUBAL, LAARNI 1310645 11/26/19 26 DR. BLUE G1P1 (1001) 1. LEVITERACETAM 12 BP: HR: RR: TEMP: O2:
VS
BARON ARANZAMENDEZ/ PREGNANCY 500MG IV Q12 100-130/80-90 89-125 20-26 34.8-37.2 100
DR. PICHAY UTERINE TERM 2. METRONIDAZOL I: 1900
CEPHLIC DELIVERED E 500MG IV Q6 - O: 600
12/13/1992 TO A LIVE BABY GIRL DAY10
AS 7, 8 VIA LTCS I FOR 3. PARACETAMOL CBG: 137, 141
ADMITTING BP: FETAL BRADYCARDIA 300MG IV Q4 PRN
160/100 (11/26/19) FOR FEVER RTC LABS:
4. LACTULOSE 12/6 CSF CS NO GROWTH AFTER 5 DAYS
ANTEPARTUM 30CC ODHS 12/6 PLACENTA HISTOPATH IMMATURE SINGLETON PLACENTA; NO FINDINGS OF
ECLAMPSIA 5. DIAZEPAM PRN PATHOLOGIC SIGNIFICANCE, CHORION AND AMNION, 3 BLOOD VESSEL UMBILICAL
5MG IV FOR CORD
S/P ARREST – FRANK SEIZURE 12/6 NA 153.19, K 4.62, BUN 6.09, CREA 24.27
EPINEPHRINE X 2 (MAX: 20MG/DAY) 12/6 NA 140.72, K 4.68, CL 104.94, BUN 6.02, CREA 19.05, CA 2.13, MG 0.83
(11/26/19) 6. OFLOXACIN 12/6 CBC 109, 0.34, 35.7, 798
DROPS; 3 DROPS 12/5 CBC (1AM): 69.0, 0.22, 15.6, 614
NEURO: BOTH EARS TID 12/5 CBC (6AM): 73.0, 0.23, 16.0, 625
POSTERIOR 7. HNBB 20MG Q6 12/5 (1AM): NA 135.80, K 2.45, CL 98.42, BUN 3.96, CREA 37.33
REVERSIBLE RTC 12/5 (6AM): NA 137.88, K 2.61, CL 100.55, BUN 4.29, CREA 39.71, CA 2.09, MG 0.70
ENCEPHALOPATHY 8. HUMAN ALBUMIN 12/4 UA STRAW HAZY 8 1.01 NEG NEG 0-1 HPF 3-8 HPF
SYNDROME PROB 20% IV Q12 12/4 TOTAL PROTEIN 45.90 ALB 28.51 GLOBULIN 17.39 A/G RATIO 1.64
SEC TO ECLAMPSIA; 9. FUROSEMIDE 12/3 CBC 97,0.30,17.4, 626
HYPOXIC ISCHEMIC 20MG IV AFTER 12/2 K: 4.0, MG: 0.76
ENCEPHALOPATHY HUMAN ALBUMIN 12/1 CBC 93, 0.29, 24.6, 404
R/O CENTRAL 10. KCL TAB TID 12/01 NA 143.77, K 2.92, AST 73.06, ALT 32.07, BUN 4.43, CREA 21.55, CA 2.21
HYPOTHERMIA 11. HNBB 2MG IV 11/30 RBS – 5.85 / ALBUMIN 26.18
RTC Q6 11/30 CSF ANALYSIS COLOR – COLORLESS / VOLUME 1CC / TRANSPARENCY – CLEAR
S/P CP ARREST (X2 12. FLUCONAZOLE / WBC - 1 CELL/UL / SEGMENTERS – 0% / LYMPHOCYTES -100% / RBC COUNT 0 %
EPI) 100MG TAB OD 11/29 CSF GLUCOSE 5.00 / CSF CHON 574
13. PIRACETAM 1.2 11/29 CBC 97 / 0.30 / 21.4 / 347
T/C PARTIALLY G/TAB Q12 11/28 CBC 90 / 0.27 / 29.1 / 343
TREATED BACTERIAL 14. DONEPEZIL 11/28 NA 145.28 / K 3.92 / CL 118.45 / SGOT 81.89 / SGPT 27.88 / BUN 5.62 / CREA 43.36 /
MENINGITIS 5MG/TAB OD LDH 579.52 / MG 0.94 / PHOS 1.22
GTC SEC TO 15. VANCOMYCIN 1 11/27 99 / 0.30 / 27 / 357
STRUCTURAL GM TIV X 12 HRS- 11/26 ETA GS: GRAM NEGATIVE BACILLI (FEW), GRAM POSITIVE COCCI IN PAIRS
ETIOLOGY DAY 2 (FEW)
16. CEFEPIME 2 GM 11/26 UA YELLOW/SLIGHTLY TURBID/PH 6/SG 1.03/ALB 2+/SUG NEG/WBC 6-8/RBC 12-
IDS: BACTERIAL TIV Q8 15
MENINGITIS - DAY 2 11/26 TSH 0.97, FT3 3.11, FT4 0.92
MGSO4 DRIP – COMPLETED 11/26 CA 2.09, MG 1.48, PHOS 1.09
CARDIO: SEPTIC 11/26 NA 143.86, K 3.91, CL 104.65, SGOT 33.54, SGPT 31.82, BUN 0.80, CREA 52.11,
SHOCK SECONDARY NICARDIPINE DRIP – LDH 288.87
TO HAP CURRENTLY ON HOLD 11/26 PT 15.2, PTT 27.9
11/26 HBA1C 5.74
S/P 1U PRBC (12/5) IVF: STEROFUNDIN 1L X 11/26 CBC 112/0.35/32.4/423
100CC/HR
S/P TRACHEOSTOMY NE DRIP X 3 CC/HR CHEST XRAY INITIAL (11/26)
G TUBE INSERTION FENTANYL DRIP X13CC/HR CLEAR LUNGS; SLIGHT PROMINENCE OF VASCULAR MARKINGS, LIKELY POSITIONAL;
ET TUBE IS 2.5CM ABOVE THE CARINA; HEART IS ENLARGED, AORTA IS NOT
DILATED; NGT TUBE TIP IS AT THE LEVEL OF L1

EEG DONE (12/02) INITIAL:

NORMAL BACKGROUND ACTIVITY
INTERMITTENT STORMING ON THE R>L TEMPOROOCCIPITAL AREA
(+) EPILEPTIFORM DISCHARGES ON BILATERAL TEMPORAL AREA

16
 CARDIO NOTES (12/5)
A>SEPTIC SHOCK SECONDARY TO HAP
SUGGEST REPEAET CXR, BLOOD CS 2 SITES
SUGGEST ETA GS/CS

OB NOTES (12/5)
FOLLOW UP OFFICIAL CXR
STILL FOR MRII TOM (SCHHEDULED)
MAINTAIN HYPOTHERMIC STATE AT 34.0
SECURE AND TRANSFUSE 1U PRBC
START KCL TAB TID X3D
(BP 70/40) NOREPINEPHRINE DRIP: 8MG IN 92CC PNSS TO MAINTAIN BP AT 100MMHG
SBP
HOLD MIDAZOLAM

NEURO NOTES: (12/7)

WILL PULL OUT HYPOTHERMIA MACHINE

PALLIATIVE CARE NOTES (12/7)

ANOINTING OF THE SICK TODAY

IM CARDIO NOTES 12/7

FF UP MRI RESULT
HOOK BACK TO NE DRIP

OB NOTES 12/7
FOR REPEAT BLOOD CS X 2 SITES, ETA CS
SOLAS 1323253 12/03/2019 35 DRS. SORIANO- 2 G3 P2 (2012) PU ATORVASTATIN 80 MG TAB 5 BP: HR: RR: TEMP: O2:
VS
MERLINDA JOSE /RAMOS DELIVERED PRETERM ODHS 100-130/70-80 70-88 20-24 36.0-36.8 97
MAYAO TO A LIVE BABY AS 7 HRZE 3 TABS OD I: 3400
VIA LTCS 1 FOR NRFS VIT B COMPLEX TAB OD O: 1350
03/24/1984 PARACETAMOL 300 MG TIV
CVD INFARCT PRN FOR HEADACHE CBG 124 116 112
STROKE IN THE ASPIRIN 80 MG TAB
YOUNG FE SO4 + FOLIC ACID TAB BID LABS
LACTULOSE 30 CC OD HS 12/6 ABG PH 7.527, PCO2 17.9, PO2 199, HCO3 15, BE -4.7, O2 SAT 99.6
S/P LTCS I KCL TAB, 1 TAB TID 12/6 BLOOD GS G(+) COCCI IN SINGLY FEW, EPITHELIAL CELLS 5-6, WBC 3-4
ERTAPENEM 1G TIV Q24 X 14 12/6 RBS 3.95, TOTAL CHON 50.31, ALB 22.25, GLOBULIN 28.06, A/G RATIO 0.79
NEURO: DAYS – DAY 6 12/6 CSF CYTOLOGY SLIGHTLY XANTHOCHROMIC, 1 CC, SL TURBID, WBC 29
ENCEPHALOPATHY PARACETAMOL 500MG/TB CELLS/UL, SEGMENTERS 60%, LYMPHOCYTES 40%, RBC NONE
MULTIFACTORIAL RTC Q4 12/6 CSF GS AFB NEG, WBC 0-3, NO MICROORGANISMS SEEN
DEXAMETHASONE 4MG TIV 12/6 CSF GLUCOSE 1.00; CSF PROTEIN 3000
A. SEPSIS PROB SEC Q6 12/5 K 3.73, LDH 263,75
TO CNS INFECTION OMEPRAZOLE 40MG TIV OD 12/5 ETA 1&2 GS G(-) BACILI, FEW; AFB SMEAR: (-)
(R/O TB MENINGITIS); 12/5 ETA 163 GS: BACILI MANY, YEAST; WBC TNTC
MILIARY TB CEFTRIAXONE 2 GM TIV – 12/5 CBC: 108, 0.32, 9.6, 296
B. HYPOXIA SEC TO SHIFTED TO ERTAPENEM 12/5: NA141.04, K 2.88, CL 123.44, BUN 1.71, CREA 43.0
HYPOPERFUSION AZITHROMYCIN 500 MG TAB 12/4 UA YELLOW CLEAR 7.5 1.01 TRACE NEG 1-3 HPF 18-20 HPF
SEC TO ANEMIA FOR 3 DAYS- D2 – 12/4 NA 134.96 K 2.92 CL 110.31 BUN 1.91 CREA 39.45
DISCONTINUED 12/4 PT 15.6 INR 1.19 APTT 27.1
CVD IN+FARCT L PCA 12/4 CBC 92.0 0.28 8.2 301
PROB SEC TO IVF: 12/3 ESR 70.00
A. HYPOPERFUSION PNSS 1L X 60CC/HR 12/3 FT3 2.07 FT4 0.83 TSH 1.60
B. VASCULITIS SEC FENTANYL DRIP 3 CC/HR-D/C 12/3 CBC 78 0.23 8.2 418
TO TB MENINGITIS STEREOFUNDIN 60CC/HR 12/3 BUN 1.78 CREA 40.24
C. CARDIOEMBOLIC 12/3 ALK PHOS 216.21 TOTAL BIL 39.00 DIRECT BIL 29.00 INDIRECT BIL 10 LIPASE
STROKE IN THE 13.52 AMYLASE 30.72
YOUNG SEC TO 12/3 DIRECT COOMBS TEST NEG INDIRECT COOMBS TEST NEG
HYPERCOAGULABLE 12/3 NA 130.77 K 2.96 CL 98.33 AST 35.61 ALT 14.85
STATE R/O APAS 12/3 PT 14.2 PT INR 1.08 APTT 26.4
12/3 RETIC COUNT 3.97
R/O CHOLELITHIASIS;
LIVER TB CXR 12/3
CONSOLIDATION ATELECTASIS RIGHT UPPER LOBE
S/P 2 UNITS PRBC T/C MILIARY TB
(12/4)
HBT UTZ 12/4
DISSEMINATED TB HEPATOMEGALY WITH FATTY CHANGES
-TB MENINGITIS CHOLECYSTOLETHIASIS WITH SIGNS OF CHOLECYSTITIS
- MILIARY TB DILATED BILIARY TREE
- T/C LIVER TB

17
CHEST CT 12/4
PTB BOTH LUNGS WITH ATELECTASIS OF RUL
PLEURAL THICKENING AND MINIMAL PLEURAL EFFUSION RIGHT
CHOLECYSTOLITHASIS

NEURO NOTES 12/7

ENSURE NEUROPRACTICE PARAMETERS
FF UP CULTURES AND GENE XPERT

SICU NOTES 12/7

D/C FENTANYL DRIP

OB NOTES 12/7
FF UP CSF CULTURES, TB GENE XPERT, BLOOD CS AND URINE GSCS
REFER TO REHAB MED
FACILITATE CRANIAL MRI WITH MRA

18