Patients Profile Name: Romeo Nalugon Age: 54 years old Procedure: CTT left (Jan 28,2012) Address: 3 sta.

Monica Compound 1, Balubaran, Malinta of Valenzuela Birthday: 09/21/1957 Occupation: driver Admission: 1/27/2012 (1pm) Admitting Physician: Cruz, Jed Patrick, M.D. Nurses Notes 1/27/2012 (1pm) F= Difficulty of Breathing (DOB) D= Admitted a 54 y/o male patient with chief complaint of DOB A= Assessed patients health status = v/s taken and recorded (1:05pm)=seen and examined by Dr. Cruz with orders made and carried out =maintain on high back rest (1:15pm)=DAT instructed =consent secured for admission (1:20pm)=referral note from Calalang General Hospital attached (2:30pm)=Hooked IVF of D5LR 1L regulated at 15gtts/min, infusing well (3:20pm)=Cefuroxime 1.5gms given TIV ANST(-) negative R=Patient still on DOB, endorsed to the next shift for continuity of care 1/27/2012 (3-11pm) (3pm) F= DOB D= received awake on bed with ongoing IVF of D5LR 1L at 950cc level; with o2 inhalation support via nasal canula (3:15pm) A= vital signs taken and recorded; R:27bpm =side rails rendered for safety =positioned on high back rest (5:30pm)=Dr. Sacro called and aware regarding undecided admission as private service

(6:55pm) R=endorsed to ward for continuity of care; RR:29bpm decreased to 20; latest BP:100/70 1/27/2012 (3-11pm) (7pm) F=DOB D= in from ER per wheelchair with D5LR going IV (+) DOB, pale A= placed on DAT, with AST precaution =placed on high back rest (8pm)=follow up referral labs from Calalang Hospital =called ER staff-Loida Tibureuo and according to her Calalang referral to their ER staff inform Dr. Sacro regarding patient thru text (9pm)= Dr. Sacro made a telephone order and carried out CBC and CXR done =secure things needed for CTT c/o Raycel Orliano (10:40pm) R=slightly dyspnic =ff up thoracostomy tube, thora bottle and connector 1/27/2012 (11pm-7am) F= pain D=on bed awake with ongoing IVF of D5LR 1L to run 15gtts/min at 900cc level infusing well masakit ang kaliwang tagiliran ko kapag huminga A= VS taken and recorded =encouraged deep breathing exercises =referred to Dr. Cruz as verbalized Bigay ka ng Tramadol 50mg stat =Tramadol given 50mg =due IV meds given Doctors Order 1/27/2012 1:00pm (+) DOB Admit to ROC under the service of Dr. Sacro TPR/ I and O with shift and recorded

 Secure consent for admission and management DAT Attach lab and x-ray result and referral note from Calalang General Hospital IVF d5LR 1Lx15gtts/min Cefuroxime 1.5g IV q8 Dr. Sacro informed VS q1hr Refer 1/27/2012 9pm Repeat CXR PA upright, left lateral dewbotus Repeat CBC Schedule for CTT left tho to ff cholecystectomy 1/28/2012 1:55am Tramadol 50mg stat IV 1/28/2012 11am initial drainage 1000ml sanguinous Post CTT infection Back to ward Monitor VS q15 DAT with aspiration precaution Continue cefuroxime 750mg, Lenfluxocin 500mg/tab Mefenamic acid 500mg Celecoxib 100mg For repeat CXR PA upright Monitor CTT output Drained 200cc q2 then clamped Unclapmed if output is less 200cc Request for GS/CS, CHON, sugar, cell cytology 11:45am Chest PA forwarded History Present Complaint: chest pain, DOB

Past History: (-) previous operation Family History: (-) familial Alcohol-occasionally Chronic smoker Systems Review Skin: (-) ischemia EENT: (-) Muskuloskeletal: (-) weakness Respiratory: occasional dyspnea Cardiovascular: (-)palpitations GI: (-)LBM GU: (-) dysuric Physical Exam Skin: (-) jaundice Head-EENT: (-) dusty looking sclera Pinkish conjunctiva Chest (+) breath sound Left. Right clear breaths CVD: (-) murmur NRRR Abdomen: non tender Extremities,Neuro, Mskulo: Full and equal pulse Admitting Impression: Pleural Effusion, massive left TPR 1/27/2012 BP:100/80 RR: 22bpm PR: 80bpm Temp: 36.5 Medications -Cefuroxime 15g TIV now then 750mg ANST (-) q8 -Tramadol 50mg TIV stat Labs CBC WBC RBC Hgb Hct MCV

18.2 H 109/L 5.83 H 1012/L 164 H g/L 49.4 % 84.7 fL

5.0-10.0 4.50-5.50 125-160 38.0-50.0 80.0-100

MCH MCHC PLT LT MO GR ROW PCT MPV POW

28.1 Pg 332 g/L 420 103/ul 17.4% 2.5% 80.1% 16.0 H % 0.29 % 3.6L fL 18.7 H %

27.0-32.0 320-360 150-400 11.0-4.0 0.0-9.0 42.0-85.0 11.5-14.5 0.08-1.00 6.0-10.0 10.0-15.0

di makatulog pumayat 160 lbs FLANAX when in pain -doesnt go on a regular check up -xray (Calalang) then referred to VMC -had a Check up last week before admission Diet: - lutong bahay -gulay (halo halo)- karaniwan -alcohol (stopped december) -Cigarette (stopped November)-smoker ever since he was in his teen years -Sleep: pagising gising, but before he sleeps for 8 hours Activity: -basketball -stretching -naglilibang through T.V -nalungkot (libang sa trabaho) -stopped working last December -good capillary refill

Radiology Report 1/23/2012 Fluid is seen in the left hemi thorax with air-fluid levels up to the 3rd anterior rib streaky infiltrates are also seen in the right lung with cystic lucencies in the right hilar area Mediastinum is deviated to the right, cardiac size cannot be assessed Impression: Pneumohydrothorax, left chronic interstitial changes, right lung with suggestive bronanestatis Interview -64 years old -Left with water -October 2011 (pain)-masakit ang tagiliran (tadyang) -smoking -alcohol -admission: yesterday(27), today (28) -Complain: DOB Pain at left lung -Driver delivery (old job: textileFabrika) -two children -Food: kinilaw na isda -elimination is OK, every morning -urine is OK -water: 2 glasses/ day -no history of other diseases -no known allergy -Diagnosis: December 2011