OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

1

NAME
AGE/
SEX
ASSESSMENT PLAN
Pascual, Rosario 78/F To Consider Urinary Tract Infection
Hypertension stage 2, uncontrolled
Diabetes Mellitus Type 2
Hyperuricemia
DASH diet, DM diet, low purine diet
Increase OFI
Dx:
FBS
TG, TC, HDL, LDL
12LECG
Urinalysis
Serum Potassium
Creatinine
BUA
WAB UTZ
Rx:
Losartan 50 mg/tab OD in AM
Captopril 25 mg SL prn for BP160/100 mmHg
Gliclazide 80 mg/tab OD
Vitamin B Complex OD
Daily BP monitoring
Daily blood glucose monitoring
For Pneumococcal vaccination
TCB once with results
Diaz, Anita 33/F Upper Respiratory Tract Infection,
probably bacterial
Nontoxic Goiter
PTB suspect
High iodine diet
Increase OFI
Dx:
CXR-PA
FT3, FT4, TSH
Neck UTZ
Rx:
N-acetylcysteine 600 mg/tab, 1 tab dissolve in 1 glass of water OD x 5 days
Amoxicillin 500 mg/cap q8h x 7 days
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



2

Multivitamins OD
TCB once with results
Agripa, Jessie 28/M Presumptive PTB
Myofascial Pain Syndrome
PTB, Treatment completed (2009,
Laguna)
Diet as tolerated
Increase OFI
Dx:
CXR-PA
DSSMx2
HBsAg
HAT
Rx:
Eperisone 50 mg/tab TID x 5days
Multivitamins OD
Mefenamic Acid 500 mg/cap q6h prn
Abstinence and contraception
TCB once with results
Balatero, Eduardo 52/M To consider Gouty Arthritis Low purine diet
Increase OFI
Dx:
CBC with PC
Creatinine
Urinalysis
CXR-PA
BUA
Bilateral Knee X-ray AP/L
Rx:
Celecoxib 200mg BID prn for pain
Multivitamins OD
Vitamin B complex OD
Apply warm compress on affected area prn
TCB once with results
Bertoldo, Edison 55/M DM Foot Infection, s/p BKA (Jan. 15, DM diet
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



3

2014, Camp Crame)
Diabetes Mellitus Type 2, uncontrolled
Dyslipidemia
Coronary Artery Disease
Osteoarthritis
Increase OFI
Dx:
For repeat FBS after 2 weeks
TG, TC, HDL, LDL
Rx:
Insulin 70/30 SC 22 units AM and 12 units PM
ISMN 30 mg OD
Trimetazidine 35 mg/tab BID
Clopidogrel 75 mg OD
Simvastatin 20 mg/tab ODHS
Daily glucose monitoring
Daily BP monitoring
TCB once with results
Malboco, Michael 41/M Chronic Hepatitis B Avoid fatty foods
Increase OFI; avoid alcoholic drinks
Dx:
SGPT, SGOT after 2 months
Rx:
Essentiale Forte TID
Multivitamins OD
Avoid needle stick injury
Practice safe sexual activities
TCB for follow-up
Batica, Amparo 60/F Upper Respiratory Tract Infection,
probably viral
To consider Allergic cough
Myofascial Pain Syndrome
Diet as tolerated, NPO while dyspneic
Increase OFI
Rx:
N-acetylcysteine 600 mg/tab in 1 glass of water OD x 5 days
Multivitamins OD
Eperisone 50 mg TID x 5 days
Cetirizine 10 mg/tab ODHS x 7 days
Paracetamol+Tramadol prn for pain
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



4

Advised Pneumococcal Vaccination
TCB after 1 week
Macalinao, Kevin John 22/M Sexually-Transmitted Infection Diet as tolerated
Increase OFI
Dx:
HBs Ag
RPR/VDRL
Urinalysis (post-treatment)
HAT
Penile discharge GS/CS
Rx:
Ceftriaxone 1 g TIM (-) ANST
Doxycycline 100 mg BID x 7 days
Multivitamins OD
Contact-tracing
Contraception/ Abstinence
TCB after 1 week
Esta, Nicanora 72/F Gouty Arthritis vs Osteoarthritis
Hypertension stage 2, controlled
Chronic Kidney Disease, stage 4
Dyslipidemia
Obese 2
Renal diet, DASH diet, low purine diet
Limit OFI 1L/day
Dx:
FBS
TC, TG, HDL, LDL
PT, PTT
12LECG
SGPT, SGOT
CXR-PA
Bilateral Knee Xray AP/L
Rx:
Losartan 50 mg OD AM
Febuxostat 40 mg/tab BID
Orphenadrine citrate + Paracetamol TID
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



5

Ketosteril TID
Amlodipine 10 mg OD PM
Vitamin B complex 1000 mg OD
Apply cold compress over affected area prn
Daily BP monitoring and record
Refer to Department of IM regarding CKD
Amar, Jizzibel 31/F Urinary Tract Infection, uncomplicated Diet as tolerated
Increase OFI
Dx:
Urinalysis (post-treatment)
CBC with PC after 1 week
Rx:
Paracetamol 500 mg/tab q4h prn T37.8C
Mutivitamins OD
Vitamin C OD
Ofloxacin 200 mg BID for 7 days
TCB after 1 week
Llamas, Epifanio 73/M Osteoarthritis vs. Gouty Arthritis
Hypertension stage 2, uncontrolled
DASH diet, Low purine diet
Increase OFI
Dx:
Bilateral knee X-ray AP/L
12LECG
FBS
Lipid Profile
CXR-PA
BUA
Creatinine
Rx:
Mefenamic Acid 500 mg/cap q6h prn for pain on full stomach
Amlodipine 10 mg/tab OD AM
Clonidine 75 mcg/tab SL prn for BP160/100 mmHg
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



6

For Pneumococcal Vaccination
Daily BP monitoring and record
TCB once with results
Nogales, Marina 71/F Hypertension stage 2, controlled
To consider Coronary Artery Disease
Hypercholesterolemia
Renal cyst, left
To consider Chronic Kidney Disease
stage 2 probably secondary to HTN
nephrosclerosis
DASH diet
Increase OFI
Dx:
CXP-PA
12LECG
FBS
Lipid Profile
Urinalysis
BUN, Creatinine
Potassium
Rx:
Losartan 50 mg/tab OD AM
Amlodipine 10 mg/tab OD PM
Simvastatin 20 mg/tab ODHS
Aspirin 80 mg/tab OD at lunch
ISMN 30 mg/tab OD
ISDN 5 mg/tab SL prn if with chest pain
Captopril 25 mg/tab SL prn BP160/100 mmHg
Vitamins + Minerals OD
Daily BP monitoring
TCB after 2 weeks
Lachita, Aurora 73/F Upper Respiratory Tract Infection,
probably bacterial
Hypertension stage 2, controlled
DASH diet,
Increase OFI
Still for:
CXR-PA
12LECG
Lipid Profile
Creatinine
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



7

Rx:
Shift Losartan to Fosinopril 10 mg/tab OD AM
Vitamin B complex 1000 mg OD
N-acetylcysteine 600 mg/tab in 1 glass of water ODHS x 5 days
Coamoxiclav 625 mg/tab TID x 7 days
Multivitamins OD
Daily BP monitoring
TCB after 1 week
Hernal, Elena 46/F Upper Respiratory Tract infection,
probably viral
To consider Allergic cough
Hypertension stage 2, controlled
Obese 2
Myofascial Pain Syndrome
To consider Coronary Artery Disease
DASH diet,
Increase OFI
Dx:
CBC with PC
Urinalysis
TC, TG, HDL, LDL
BUN, Creatinine
FBS
CXR-PA
12LECG
Rx:
Losartan 50 mg/tab OD AM
Multivitamins OD
N-acetylcysteine 600 mg/tab in 1 glass of water ODHS for 5 days
Paracetamol 500 mg/tab q4h prn for T37.8C
Tramadol+Paracetamol 37.5/325 mg q8h prn for pain
Cetirizine 10 mg/tab ODHS for 14 days
Daily BP monitoring
Regular exercise
Weight reduction
Avoid triggering factors of cough
TCB after 1 week
Heraldo, Ervin 42/M Edema probably secondary to CHF or DASH diet, renal diet
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



8

CKD
PTB, ongoing treatment x 2 months
(April 2014, Caloocan HC)
Hypertension stage 2, uncontrolled
Limit OFI to < 1L/day
Dx:
CXR-PA
12LECG
Urinalysis
BUN, Creatinine
SGPT, SGOT
CBC with PC
Rx:
Furosemide 40 mg/tab OD x 3 days
Olmesartan+HCTZ 40/12.5 mg OD AM
Multivitamins OD
Continue anti-Kochs c/o TB-DOTS
Daily BP monitoring and record
TCB once with results
Equibal, Wilfredo 61/M To consider Rotator cuff tendinitis
Diabetes Mellitus, type 2,
uncontrolled
Osteoarthritis
Dyslipidemia
DM diet
Increase OFI
Dx:
HbA1c
Shoulder X-ray, left AP/L
Rx:
Celecoxib 200 mg BID prn for pain
Vitamin B complex 1000 mg/tab OD
Metformin 500 mg/tab BID
Metformin+Sitagliptin 500/50 mg OD
Simvastatin 20 mg/tab ODHS
Regular BP monitoring
Apply warm compress on affected area prn
TCB once with results
Zapamanya, Melencio 46/M Hypertension stage 2, uncontrolled
Diabetes Mellitus type 2, uncontrolled
DM diet, DASH diet
Increase OFI
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



9

Dx:
Urinalysis
CXR-PA
12LECG
BUN, Creatinine
TC, TG, HDL, LDL
FBS
HbA1c
Rx:
Shift Metoprolol to Losartan 50 mg/tab OD AM
Amlodipine 10 mg/tab OD PM
Captopril 25 mg/tab SL prn for BP160/100 mmHg
Metformin XR 1g/tab ODHS
Glimepiride 2mg/tab OD AM
Daily BP monitoring
Regular BG monitoring
TCB after 2 weeks
Loayan, Jonathan 34/M Diabetes Mellitus type 2, uncontrolled DM diet
Increase OFI
Dx:
FBS after 2 weeks
HbA1c after 3 months
Rx:
Intermediate Insulin 30 units AM, 15 units PM SQ
Sitagliptin 100 mg/tab OD
Vitamin B complex + Vitamin E (Neurogen E) OD
Daily BG monitoring and record
TCB after 2 weeks
Siribar, Valentina 74/F Bells Palsy
Hypertension stage 2, controlled
DASH diet
Increase OFI
Rx:
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



10

Discontinue Methylprednisolone
Amlodipine 10 mg/tab OD
Multivitamins OD
Continue acupuncture sessions
Daily BP monitoring
TCB once with problems
Beltran, Normelita 68/F Diabetes Mellitus, type 2, controlled
Hypertension stage 1, controlled
Hyperlipidemia
DM and DASH diet
Increase OFI
Dx:
For TC, TG, HDL, LDL on July 22, 2014
Rx:
Metformin 500 mg/tab TID
Gliclazide 80 mg/tab OD
Losartan 50 mg/tab OD AM
Simvastatin 40 mg/tab OD HS
Vitamin B complex BID
Continue regular BP monitoring and record
Regular BG monitoring
Exercise daily
TCB after 3 weeks with lipid profile result
Goyon, Myrna 63/F Upper Respiratory Tract Infection,
probably viral
To consider Hypertension
Obese 1
DASH diet
Adequate OFI
Dx:
Urinalysis
TC, TG, HDL, LDL
FBS
CXR-PA
12LECG
Creatinine
SGPT
Rx:
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



11

N-acetylcysteine 600 mg/tab in 1 glass of water OD HS x 5 days
MV+Zinc OD
Lagundi 600 mg/tab q8h x 5 days
Advised Pneumococcal vaccination
Daily BP monitoring and record
Regular exercise
TCB once with results
Leoncio, Jogno 60/M Hypertension stage 2, controlled To
consider Coronary Artery Disease
To consider Benign Prostatic
Hypertrophy

DASH diet
Increase OFI
Dx:
Urinalysis
12LECG
TC, TG, HDL, LDL
FBS
CXR-PA
KUB-UTZ with prostate
BUN, Creatinine
Rx:
Amlodipine 5 mg/tab OD AM
Multivitamins OD
Trimetazidine 35 mg/tab BID
Daily BP monitoring and record
TCB once with results
Yamit, Marvin 25/M Neurocirculatory Asthenia
To consider Substance Withdrawal
Syndrome secondary to
Methampethamine Abuse
Diet as Tolerated
Increase OFI
Dx:
12LECG
CXR-PA
Rx:
Discontinue Atenolol and Levocetirizine
To start with Vitamin B Complex BID
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



12

Brown bag mask ventilation prn
Suggest Psychiatry consult
Advised consult to Toxicology Department, PGH
Albario, Liza 62/F To consider Congestive Heart Failure
Hpyertension stage 2, uncontrolled
DM suspect
DASH diet
Increase OFI
Dx:
Urinalysis
12LECG
TC, TG, HDL, LDL
FBS
CXR-PA
BUN, Creatinine
Na, K
Rx:
Losartan+HCTZ 50/12.5 mg/tab OD AM
Multivitamins OD
Trimetazidine 35 mg/tab BID
Clonidine 75 mcg/tab SL prn for BP160/100 mmHg
Daily BP monitoring and record
Watch out for signs of DOB, shortness of breath, chest pain, and proceed to IM-ER
TCB after 1 week
Atibagos, Felisa 59/F Hypertensive Cardiovascular Disease,
NSR, to consider CHF, II-B
Dyslipidemia
To consider Chronic Kidney Disease
probably secondary to HTN
nephrosclerosis
Tension Headache
DASH diet
Adequate OFI
Dx:
Urinalysis
TC, TG, HDL, LDL
FBS
CBC with PC
BUN, Creatinine
Na, K
KUB-UTZ
OSPITAL NG MAYNILA MEDICAL CENTER
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE



13

Rx:
Losartan+HCTZ 50/12.5 mg/tab OD AM
Trimetazidine 35 mg/tab BID
Aspirin 80 mg/tab OD at lunch
Simvastatin 20 mg/tab OD HS
Captopril 25 mg/tab SL prn for BP160/100 mmHg
ISDN 5 mg/tab SL prn for chest pain
Paracetamol+Orphenadrine 1 tab prn
Furosemide 40 mg/tab OD x 3 days
Multivitamins OD
Daily BP monitoring and record
Watch out for signs of DOB, shortness of breath, chest pain, and proceed to IM-ER
TCB after 1 week
Roco, Juliet 65/F To consider Community-Acquired
Pneumonia, low-risk
Nephrolithiasis, bilateral, on
treatment
Hypertension stage 1, controlled
Hyperuricemia
Low purine diet, DASH diet
NPO if dyspneic
Adequate OFI
DX:
KUB-UTZ (on August 2014)
Serum Na, K
Urinalysis
Creatinine
Rx:
Losartan 50 mg/tab OD AM
N-acetylcysteine 600mg in 1 glass of water OD HS x 5 days
Sambong cap TID
Multivitamins OD
Co-amoxiclav 625 mg/tab q8h x 7 days
Daily BP monitoring
Advised Pneumococcal Vaccination
TCB once with results