JOSE R.

REYES MEMORIAL MEDICAL CENTER

DEPARTMENT OF HEALTH
OBSTERTRICS AND GYNECOLOGY DEPARTMENT
CONSULTANT: Dr. Co
RESIDENTS: Joves/Gadin/Acosta/Donato, Gutierrez
POST GRADUATE INTERNS: Beroin, Gabayeron, Pescante M, Prodigo, Sese, Sevilleja, Tiu
JUNIOR INTERNS: Alonzo, Padilla, Gagan
August 25-26 2016

NUMBER OF PATIENTS
LR/DR: OB-GYN WARD
SEPTIC: 0 NEW ADMISSIONS:

OB PATIENTS (OB WARD): 17 OB WARD: LR/DR:

GYNE WARD: PACU:
GYNE-ONCO WARD: POST OP:
PAY:

GYNE PATIENTS (GYNE WARD): 11 DISCHARGED:

WARD:
PAY: 0
LR/DR: 0
GYNE-ONCO: 8 TRANSFER OF SERVICE 0
HIGH RISK/ISO: 1 MORTALITY 0
POST-OP: 15 HAMA/HOME PER REQUEST 0
OB ER: ABSCONDED 0
PACU/SICU/PICU/MICU/FEMALE SURGICAL WARD: 1 THOC 0

PAY: 5 OB WARD: 17
GYNE WARD: 11
GYNE-ONCO WARD: 8
ISO: 2
HIGH RISK:1
POST OP: 15
LR/DR:
SEPTIC: 0
PAY: 5
PACU/SICU/MICU/FEMALE SURGICAL: 1

TOTAL PATIENTS:

HIGH RISK (1)

HR 2016061759 Delarmente, Lucy G5P4(4004) 30 2/7 For BP control 1. Nicardipine Drip: PNSS 90cc LSLF UREMIC diet with
2 wks AOG by LMP, CBC 8/9/16 8/15 8/21 + 10mg Nicardipine to run at Na < 2g/day
Drs: 38 CNIPTL, Hgb 10.2 10.1 9.4 10ugtts/min then titrate to No fruit, fruit juices,
Bernardino/ Joves/ Iskandar, Morante/ preeclampsia with 2ugtts/min every 30minutes milk/milk products
Hct 29.5 29.2 27.8
Acosta/ Beron, Cuenco G5P4 severe features to achieve SBP <140mmHg
RBC 2.98 2.82 2.8 Limit OFI to < or = to 1
2. Hydralazine 5mg SIVP for BP
WBC 9.22 7.50 7.22 Cont IVF at KVO
8/10/16 O+ >160/100 once in nicardipine
Neu 80.3 73.8 71.8 drip Nicardipine at 30 gtts/m
Lym 13.3 14.1 18.4 3. Methyldopa 250mg /tab, 2 Follow up CXR result
Bas 0.3 0.4 0.4 tabs Q6 Follow up 2d echo resul
Mon 5.4 6.9 7.3 (6am-12pm-6pm-12am) referral back to IM
4. Nifedipine 30mg tablet every Cardio once in
Eos 0.7 4.8 2.1
6hrs Daily NST
Plt 197 186 193 (9am-3pm-9pm-3am) Weekly BPS
PT/PTT 8/9/16 5. Metoprolol 50mg/tab 1 tab Doppler study every 2
BID weeks
CT 330 (after breakfast and after
VS FHT Q1 waking hour
BT 7.403 dinner)
only
ISDN 5 mg/tab 1 tab SL q3
mins PRN for chest pain
UA 8/9/16 maximum of 3 doses
Color Light yellow 6. MV + amino acid / tab OD
Characteristic Slightly turbid 7. Ca + Vit D BID
pH 5.5 8. Cefuroxime 1.5g TIV q8
Spec Gravity >1.030 9. FeSO4 BID
Sugar Negative
Protein trace
RBC 0-1
WBC 3-5
Bacteria Many
Epithelial cells few

ABG 8/10
PH 7.403
PO2 107.3
PCO2 28.3
O2 SAT 98
BE -5.9
Metabolic Acidosis
Dully compensated
Overcorrected Hypoxemia

8/9 8/10 8/11 8/12 8/15 8/22 8/23 8/2

4
BUN 14.2
SGOT 8.01
SGPT 7.81 7.50 8.30
K 3.37

Crea 154 171 152 190 190

LDH 223 229
FBS 5.28
Choles 6.37
Trigly 2.58
HDL 1.19
LDL 4.01
24 912.60
hour
urine
CHON
Total Ca 1.93

THORACIC UTZ: 98/12/15)

-Minimal pleural effusion, Left (20-30cc)
Xray : pulmonary congestive changes
Sputum G/S:
Pus Cells: Few
Epithelial Cells: None Found
Gram + cocci: None Found
Intracellular gram diplococcic: None Found
Extracellular gram diplococcic: None Found
Urine C/S:
No growth after 48 hour incubation under aerobic condition
UTZ 8/11/16: Pregnancy uterine live singleton of about 30 weeks and 5 days by fetal biometry in breech
presentation; placenta posterior grade II high lying; Normohydramnios
8/15/16: Troponin I - <1.0

8/24/16: KUB UTZ (i): Bilateral renal parenchymal disease grade 1 with perirenal fluid collection, right.
Correlate with UA.

OB WARD (17)
4 2016066502 PRADO Mariz G4P3 (3003) PU 35 G4P4 (4004) PU For NSD S/P partial CBC 8/26 1. Oxytocin 10 u IM before delivery of For IE 4-6 hours post
5/7 wks AOG delivered term breech Hgb 8.4 placenta partum
breech baby boy extractio Hct 28.0 2. Cefalexin 500 mg /tab 1 tab Q6 x 7 Daily perineal
23 days
RBC 4.15 hygiene
3. Mefenamic acid 500 mg tab q6 PRN Frequent
WBC 11.15
Dr. Bernardino/Alava/Angkawijaya/Acosta/ G4P3 4. MV OD breastfeeding
Neutro 74.4 5. FeSO4 BID
Wof: profuse vaginal
6. Ca+vit D BID
Beron, Cuenco Lympho 16.3 bleeding
Baso 0.8
Mono 7.4
B+
Eos 1.1
PLT 381
8/26/16

5 2016013061 GARDOSE G2P0 (0100) 33 2/7 G2P1 (0201) For NSD s/p NSD with CBC 8/25 1. Cefalexin 500 mg /tab 1 tab Q6 x 7 IVF to consume
Glendalyn wks AOG pregnancy right Hgb 14.3 days VSq4
uterine preterm mediolateral Hct 39.2 2. Mefenamic acid 500 mg tab q6 PRN
Dr. Tan /Gadin/ Acosta/ Donato / Gutierrez/ 3. MV OD
cephalic episiotomy RBC 4.43
delivered and repair 4. FeSO4 BID
WBC 16.73
spontaneously to under local 5. Ca+vit D BID
Neutro 77.7
20 y.o a live baby boy anesthesia
8/26/2016 with AS 8,9 Lympho 17.3
A+ ballard score of Baso 0.3
35 wks, Mono 3.9
birthweight of Eos 0.8
2200 gms, PLT 307
appropriate for
gestational age
6 2016066053 REDUCCION G13P3 (3093) PU 41 G13P4 (4094) PU For NSD s/p NSD with CBC 8/25 1. Cefuroxime 500mg/cap 1 DAT
Ma. Lourdes 1/ wks term cephalic perineal Hgb 11.6 cap q6 x 7 days For E BTL
Drs. Tagayuna / Cartagena / Angkawijaya / CHUA / Cuenco, delivered support Hct 35.0 2. Mefenamic acid 500,g/cap 1
Beron 26 spontaneously to cap q4 PRN for pain
RBC 3.77
a live baby boy 3. FeSo4 1 tab BID
WBC 11.34
G13P4 with AS 8,9 BS 4. Ca+ vit D 1 tab BID
Neutro 70.4
8/25/16 40 wks BW 2500
A+ gms appropriate Lympho 23.0
for gestational Baso 0.3
age Mono 5.4
Eos 0.9
PLT 302
UA 8/25
Color Light Yellow
Characteristic Slightly turbid
Reaction 6.5
SG 1.025
Sugar Negative
protein Negative
RBC 0-1
WBC 2-4
Bacteria Many
Epithelial cells Few

8/26
Creatinine 36.00
Na 134.30
K 3.89
8/25
Clotting time 330
Bleeding time 230
Prothrombin time 12.1
PT control 13.4
PT INR 1.00
PT % Activity 100
7 504305 GARCIA, G2P1 (1001) PU 38 G2P2 (2002) PU For NSD S/P Normal CBC 8/24 1. Co-Amoxiclav 625 mg /tab 1 tab BID x 7 Soft diet
Alexandra weeks AOG by LMP; delivered spontaneous Hgb 14.4 days For IE prior to
Dr. Madera/Halim, Cartagena/Morante/Quimba/ CIBL, spontaneous spontaneously to delivery with Hct 42.7 2. Mefenamic acid 500 mg tab q6 PRN discharge
Corpuz, Montemayor 25 rupture of a live term baby median 3. MV OD VSq4
RBC 4.66
membranes x girl with AS , episiotomy 4. FeSO4 BID
WBC 10.45
8/24/16 G2P1 5hours BS , BW and repair of 5. Ca+vit D BID
Neutro 68.3 6. Senokot ODHS
4th degree
7. Metronidazole 500mg/tab TID x 6 days
A+ laceration Lympho 18.4
under local Baso 0.4
anesthesia Mono 11.1
Eos 1.8
PLT 314
UA 8/24/16
Color Orange
Characteristic Turbid
pH 6.5
Spec Gravity 1.015
 Sugar Negative
Protein trace
RBC Over 100
WBC None found
Bacteria None found
Epithelial cells few
8 2016039884 VILLAESTER, G1P0 PU 38 5/7 G1P1 (1001) PU For NSD S/P Normal CBC 8/25 1.Cefalexin 500 mg/cap q6 x 7 days MGH once with IM-
Ailyn weeks AOG by LMP term, cephalic, spontaneous Hgb 13.3 2.FeSO4 BID endo clearance prior
delivered delivery with Hct 40.2 3.MV OD to discharge
Dr. Bernardino/ Halim, Cartagena/ Morante/Quimba/ 4.Ca + Vit D BID
spontaneously to right RBC 5.11 Refer to IM-Endo for
a live baby boy mediolateral 5.Mefenamic acid 500 mg/tab q6 PRN x pain clearance
WBC 13.94
Corpuz, Montemayor APGAR __8,9_, episiotomy Neutro 76.5
20 BW _3400gms__, and repair and
8/25/16 BS _39__, AGA local Lympho 14.4
anesthesia Baso 0.3
Mono 7.2
Eos 1.6
G1P0
PLT 248
UA 8/25/16
Color Yellow
Characteristic Clear
O+ pH 6.0
Spec Gravity <1.005
Sugar Negative
Protein Negative
RBC 10-15
WBC 1-2
Bacteria few
Epithelial cells few
10 2016065806 REGALARIO, G3P2 (2002) PU 34 G3P3(3003) PU For NSD Normal CBC 8/26/16 1. Cefalexin 500 mg /tab 1 tab Q6 x 7 Daily perineal hygiene
Cindy weeks AOG by LMP term cephalic spontaneous Hgb 9.1 days MGH once with normal
Dr. Bernardino/Alava/Angkawijaya/Acosta/ CIL delivered delivery with Hct 30.0 2. Mefenamic acid 500 mg tab q6 PRN results
21 spontaneously to perineal 3. MV OD IVF to consume once with no
a live term baby support and RBC 4.03 4. FeSO4 BID active bleeding
Beron, Cuenco 5. Ca+vit D BID
G3P2 boy AS 8,9 BS 37 repair of 1st WBC 9.95 UA
wks, BW 2400 degree 6.
gms AGA laceration Neu 71.7
under local Lym 20.4
8/23/16 anesthesia
Baso 0.2
Mon 6.0
Eos 1.7
Plt 306
UA 8/25
Color Yellow
Transparency Clear
pH 6.5
Spec Gravity 1.020
Protein Negative
Ketone Negative
Sugar Negative
RBC 10-15
WBC 2-4
Bacteria Few
Epi cells few
15 2016066657 LEGASPI Imelda G6P4 (5015) PU 40 G6P5 (5015) PU For NSD Normal CBC 8/26/16 1. Cefalexin 500 mg q6 x 7days IVF D5LR 1 liter
5/7 wks AOG by delivered term spontaneous Hgb 11.6 2. Ferrous sulfate BID WOF profuse vaginal
8/26/16 39 LMP, CIL cephalic live delivery with Hct 35.5 3. Multivitamins OD bleeding
baby girl with AS perineal 4. Oxytocin 10 u before delivery of placenta VSq4
G6P4 8,9 BS 39 wks support and RBC 3.99
BW 3200 gms repair of 1st WBC 9.95
A+ AGA later latent degree
syphilis laceration IUD Neu 77.5
insertion Lym 14.2

Baso 0.4
Mon 6.3
Eos 1.6
Plt 262
16 2016066736 QUIRANTE Mary Early pregnancy 6 For BT CBC 8/25/16 1. Duphaston 10 mg 4 tabs q8 Secure and transfuse 4 u of
rose weeks Hgb 67 2. Feso4 +folic acid OD PRBC properly typed and
8/26/16 Hct 0.20 3. MV OD crossmatched
23
RBC 2.3 Refer to IM hema once at the
WBC 11.3 ward

Neu 61.9 WOF BT reactions, severe

Lym 32 hypogastric pain, profuse
vaginal bleeding
Baso
Mon 6.1 For PT,PTT and CT, BT once
Eos at the ward
Plt 120
17 2016049153 MANTOS, G1P0 PU 37 1/7 G1P1 (1001) PU For NSD NSD with right CBC 8/25/16 1. Shift Cefalexin 500 mg/cap to Ofloxacin MGH once with NBS
Amilyn weeks AOG by UTZ term, cephalic, mediolateral Hgb 11.3 400mg/cap q12 for 7 days Increase oral fluid intake
Dr. Madera/Halim, Cartagena/Morante/Quimba/ delivered, epsiotomy, Hct 33.6 2. FeSO4 BID
Corpuz, Montemayor 20 spontaneously to and repair 3. MV OD
a live term baby under local RBC 3.88 4. Ca + Vit D BID
8/25/16 G1P0 girl, APGAR , BS anesthesia 5. Mefenamic acid 500 mg/tab q6 PRN x pain
WBC 20.38
weeks,
O+ birthweight g Neu 78.7
Lym 12.0

Baso 0.3
Mon 9.0
Eos 0.0
Plt 387
UA 8/25
Color Yellow
Transparency Turbid
pH 7.0
Spec Gravity 1.010
Protein Negative
Ketone Negative
Sugar Negative
RBC None
WBC Over 100
Bacteria Moderate
Epi cells few
18 20160657111 DE CASTRO, G2P2 (2001) For NSD s/p NSD CBC 8/23/16 1. Co-amoxiclav 625 mg BID x 7 days MGH
Princess IUFD 37 3/7 Hgb 12.5 2. FeSO4 BID VS Q4
Dr. Bernrdino/Alava/Angkawijaya/Acosta/Beron, Corpuz weeks AOG by Hct 35.9 3. MV OD
21 y.o LMP delivered 4. Mefenamic acid 500 mg/tab q6 PRN x pain
8/23/2016 spontaneously to RBC 3.99
A+ a stillborn baby WBC 8.93
girl
Neu 67.4
Lym 22.1

Baso 0.2
Mon 6
Eos 4.3
Plt 228
UA 8/23
Color Straw
Transparency Slightly turbid
pH 6.5
Spec Gravity 1.020
Protein -
Ketone -
Sugar -
RBC -
WBC 1-3
Bacteria Few
Epi cells few
19 832313 DAYAG, G2P0 PU 36 wks G2P2 (2002) For NSD s/p NSD and CBC 8/22 5. Cefuroxime 500 mg BID x 7days MGH
ANGELICA AOG Pregnancy IUD insertion Hgb 10.7 6. Mefenamic acid 500mg cap q6 PRN for pain Follw-up 8/30/16
Dr. Perez / Locaylocay/ gadin / Quimba/ Donato, Gutierrez uterine, preterm, Hct 32.7 7. Ferrous sulfate BID
cephalic, 8. Multivitamins OD
RBC 4.41
delivered 9. Calcium + vit D3 BID
WBC 9.29
21 Y spontaneously,
Neu 76.0 10. Paracetamol 300mg IV q4 PRN for T > 38
8/22/16 to a live baby
Lym 12.1
G2P1 boy with AS 8,9
Bas 0.2
BS 39 wks, BW
2900 grams, Mon 11.6
AGA, URTI, IUD Eos 0.1
acceptor Plt 188
 UA 8/21
Color light Yellow
Characteristic S. turbid
Reaction 7.0
SG 1.010
Sugar Negative
protein Negative
RBC 1-30
WBC 30- 40
Bacteria moderate
19 2016066523 EVIOTA G1p0 PU 41 2/7 wks G1P1 (1001) PU For NSD NSD with right CBC 8/26 1. Cefalexin 500 mg/cap q6 x 7 days DAT
Dr. Cuenca/ locaylocay/ angkawijawa/ quimba/beron ,cuenco Bernalie AOG delivered term mediolateral Hgb 12.0 2. FeSO4 BID IVF to consume
cephalic live episiotomy Hct 34.6 3. MV OD WOF profuse vaginal
8/26/16 23 baby girl with AS and repair 4. Ca + Vit D BID bleeding
RBC 3.91
8,9 BS 40 wks under local 5. Mefenamic acid 500mg/tab q6 x
WBC 20.49 7days
G1p0 PU 41 2/7 BW 3200 gms anesthesia
wks AOG AGA Neu 81.0
Lym 12.0

Bas 0.2
Mon 56.1
Eos 0.7
Plt 394
20 2016066377 Villaflores Mary G1P0 PU 37 wks G1P1 (1001) PU For NSD s/p NSD with CBC 8/25 6. Cefalexin 500 mg/cap q6 x 7 days MGH once with normal U/A
Dr. Tan/Joves/Gadin/Acosta/Donah/Gutierrez ann AOG delivered right Hgb 11.7 7. FeSO4 BID result
spontaneously to mediolateral Hct 36.9 8. MV OD Daily perineal hygiene
8/25/2016 20 alive baby boy episiotomy 9. Ca + Vit D BID Encourage breastfeeding
RBC 4.45
with AS 8,9 and repair 10. Mefenamic acid 500mg/tab q6 x
WBC 18.28 Ff.up at OB-OPD on 9/5/16
G1P0 birthweight of under local 7days
2600gm ballard anesthesia Neu 78.7
O+ score of 38 wks, Lym 15.3
appropriate
gestational age Bas 0.3
Mon 5.3
Eos 0.4
Plt 320

21 904683 BAGUINONG, G3P2 (2002) PU 38 G3P3 (3003) PU For NSD s/p NSD CBC 1. Cefalexin 500mg/tab 1 tab q6 PRN MGH once with
Hernaliza weeks AOG by LMP; term, cephalic, Hgb for pain normal lab results
CIL delivered Hct 2. FeSO4 cap BID Follow up on 9/6/16
Dr. Bernrdino/Alava/Angkawijaya/Acosta/Beron, Corpuz 3. Multivitamins cap OD
23 y.o spontaneously to 7am
a live baby girl RBC 4. Ca + Vit D3 cap BID
8/23/2016 5. Mefenamic acid 500mg/cap PRn for
WBC pain
Neu
Lym

Plt

UA 8/24
Color Yellow
Characteristic Clear
Reaction 7.0
SG 1.015
Sugar negative
Protein negative
RBC 5-10
WBC 1-3
Epithelial Few
Bacteria Many
22 2016048094 HERNANDEZ G1P1 (1001) PU 41 G2P2(2002) PU For NSD s/p NSD with CBC 8/25 1. Cefalexin 500mg/tab 1 tab q6 PRN for MGH once with NBS
Ma. Theresa 2/7 wks AOG cephalic right Hgb 14.4 pain Cont medications
delivered mediolateral Hct 49.0 2. FeSO4 cap BID
Dr. Madera /Halim/ Morante 3. Multivitamins cap OD
25 spontaneously to under repair RBC 5.00
a live term baby and local 4. Ca + Vit D3 cap BID
WBC 9.78 5. Mefenamic acid 500mg/cap PRn for pain
O+ girl AS 8,9 BS 38 anesthesia
wks BW 3000 Neu 69.5
G1P1 Gms AGA Lym 20.9

Bas 0.5
Mon 8.9
Eos 1.9
Plt 236
UA 8/25
 Color light yellow
Characteristic Clear
Reaction 6.0
SG 1.015
Sugar Neg
protein Neg
RBC 1-2/hpf
WBC 0-1/hpf
Epithelial Few
Bacteria few
Mucus threads none found
23 2016065995 PADILLA, Inah G2P1 (1001) PU 38 G2P2 (2002) PU For NSD s/p NSD; IUD CBC 8/24 6. Cefalexin 500mg/tab 1 tab q6 PRN for MGH once with NBS
2/7 weeks AOG by term, cephalic, acceptor Hgb 8.5 pain Once iron sucrose
LMP; PROM x 14 delivered Hct 28.4 7. FeSO4 cap BID was given
hours spontaneously to 8. Multivitamins cap OD Ff.up on 9/9/16
RBC 3.88
a live baby girl 9. Ca + Vit D3 cap BID
WBC 9.87 10. Mefenamic acid 500mg/cap PRn for pain
Dr. Madera/Halim, Cartagena/Morante/Quimba/Corpuz, 20 y.o APGAR 8,9, AGA
Montemayor Neu 66.8
Lym 24.7

Bas 0.3
G1P0
8/24/2016 Mon 7.7
Eos 0.5
Plt 421

AB+

24 2016033554 QUINTAL G1P0 PU 39 4/7 wks G1P1 (1001) PU For NSD s/p NSD with UA 8/26 1. Cefalexin 500mg/tab 1 tab MGH once with U/A
Rachel AOG cephalic perineal Color light yellow q6 PRN for pain
delivered support and Characteristic slightly turbid 2. FeSO4 cap BID
DR. Tan/joves/Gadin/Acosta/Donato/gutierrez 3. Multivitamins cap OD
spontaneously to repair 2nd Reaction 6.0
21 4. Ca + Vit D3 cap BID
a live baby boy degree SG 1.015
8/25/16 with AS 8,9 BS laceration 5. Mefenamic acid 500mg/cap PRn for pain
Sugar Neg
G1P0 39 wks BW 2300 under local protein Neg
gms AGA anesthesia RBC >100/hpf
A+ WBC 1-3/hpf
Epithelial Few
Bacteria few
Mucus threads none found

CBC 8/25
Hgb 13.6
Hct 39.4
RBC 4.49
WBC 20.16

Neu 88.4
Lym 8.2

Bas 0.2
Mon 3.2
Eos 0.0
Plt 207
OB EXTENSION (8)
0 2016064655 MIPA, Marlyn G3P1 (1011) t/c G3P1 (1021) Medical Management s/p Ex Lap, w/ CBC 8/20 8/21 1. Cefalexin 500mg 1 cap Q6 DAT
1 Ectopic Acute Abdomen TAHBSO Hgb 14.5 12.6 7days heplock
Drs. 30 Pregnancy 10 secondary to (8/20/16) Hct 44.5 39.4 2. MV OD For B-HCG af
Tagayuna/Cartagena,Halim/Angkawijaya/Chua/Beron/Cuenc 4/7 wks AOG by Ruptured RBC 5.43 4.79 3. Mefenamic acid 500mg Q6 days
o G3P1 LMP unruptured, Gestational PRN for pain
WBC 3.08 7.58 Daily cod
t/c cornual Throphoblastic 4. FeSO4 tab BID
Neu 52.0 88.5 Maintain abdo
B+ Tumor 5. Klyte 1 tab TID for 5 days
Lym 35.1 7.8 6. Mupirocin ointment BID binder
Mon 11.7 3.6 7. Methotrexate 0.8 ml TIM Encourage
Eos 0.6 0 OD x 5 if ok with senior ambulation a
Plt 263 233 daily perineal
hygiene
UA 8/20 VSQ4
Color light yellow
Characteristic slightly turbid
Reaction 6.5
SG 1.010
Sugar neg
protein neg
RBC 4-6/hpf
WBC 2-4/hpf
Epithelial many
Bacteria few
Mucus threads none found

8/21 8/22
CT 530
BT 230
B-HCG 1672
PT 13.1
PT 13.4
control
PT INR 1.00
PT % 100
BUN 1.9
Crea 60.00
FBS 5.03
SGPT 27.8
LDH 232
0 2016064725 CORTEZ, G2P1 (1000) PU G2P2 (2001) PU d primary LSCS S/P Primary CBC 8/20 1. Amlodipine 10mg/tab MGH today
2 Grace 38 3/7 wks AOG Term cephalic LSCS Hgb 14.8 OD Aily Perineal Hygiene
Drs. Tagayuna/Cartagena/Angkawijaya/Chua/Cuenco,Beron by LMP, delivered Hct 43.6 2. FeSO4 BID Daily COD
37 oligohydramnios, operatively to a 3. Ca BID
RBC 4.89 For Follow up at OPD
CIBL, Myoma live baby boy, AS 4. MV OD
WBC 121.49 8/30
G2P1 uteri , pre- __, BS__, BW 5. Clonidine 75mcg/tab 1tab
Neu 64.4 Follow up at cardio af
eclampsia w/ ______ GA SL for BP > 160/100
O+ non-severe Lym 27.3 6. Cephalexin 500mg/cap, 1
features Mon 6.5 cap Q6 for 7 days
Eos 0.9 7. Tramadol 50 mg/tab 1 tab
Plt 164 Q8 PRN for pain
8. Metoprolol 50mg / tab 1
UA 8/20 tab Q12 (8 Am and 8pm)
Color Yellow
Characteristic Clear
Reaction 6.5
SG 1.030
Sugar Negative
protein 2+
RBC 10-15
WBC 0-2
Epithelial Mod
Bacteria Few

8/20

BUN 4.90
Crea 59.26
Na 143.80
K 3.73

8-22-16
SGPT 26.6
LDH 600
24hr urine 1302.46
0 2016064983 DONAYRE, G1P0 PU 37 1/7 G1P1 (1001) PU For D CS S/P Primary CBC 8/22 8/24 Amlodipine 10mg/tab OD DAT once with BM
3 Rosemarie weeks AOG by delivered Low Segment Hgb 12.1 8.1 if BP > 140/100 IVF to consume
Drs. Valencia/ Locaylocay/Gadin/Quimba/Donato, Gutierrez LMP, CIBL, PROM operatively to Cesarean Hct 35.1 24.8 Co- amoxiclav 625mg Q12 For COD post op day
22/F x 7 hours; Pre- alive term baby Section x7days
RBC 4.21 2.79 Daily perineal hygien
8/22/16 eclampsia, girl with AS 8,9; MV OD
WBC 13.67 11.15 WOF: profuse vaginal
A+ Severe BS 38 weeks ;
Neu 76.4 75.8 FeSo4 cap BID bleeding
BW 2500g AGA
Lym 17.8 17.8 Ca+ Vit D tab BID For BT of 2 units of pR
Mon 4.5 4.9 Mefenamic Acid 500mg/ For repeat CBC post B
 Eos 1.0 1.1 tab 1 tab Q6 PRN for pain U 6 hours post BT
Plt 310 144

8/22 8/24
SGPT 8
LDH 203
K 3.60
24 Urine Chon 418.17

0 1001035 MERIDOR, G5P2 (2022) PU For augmentation of CBC 8/25 Ampicillin 2 gm/IV Q6 for 3 NPO
4 Honorata 36 6/7 weeks labor s/p LSCS with Hgb 15.7 more dose 1 U PRBC transfused
Dr. Carino AOG by 2nd BTL Hct 43.2 MgSO4 drip PNSS 1L + WOF BT reaction
43 trimester UTZ, RBC 5.24 10g MgSO4 x 100 gtts/hr
8/25/16 CIBL; pre to complete 24 hrs
WBC 7.74
G5P2 eclampsia, Diphenhydramine 1 amp
severe Neu 52
Lym 38.2 TIV 30 min Prior to BT
AB+
Plt 153

UA 8/25
Color Yellow
Characteristic Sl. turbid
Reaction 6.0
SG 1.015
Sugar Negative
protein 2+
RBC 30-40
WBC 0-3
Epithelial Mod
cast 2-4

0 2016059352 MANUZON, G2P2 (2002) Gravida 2 Para 2 S/PRepeat Low CBC 8/23 8/24 Cefalexin 500mg q6x7d MGH today
5 Mary Grace (2002) Pregnancy Segment CS Hgb 11.0 9.9 MV tab OD Take home meds
Dr. Bernardino/Alava/Angkawijaya/Acosta/ Uterine Delivered Hct 32.8 30.5 FeSO4 tab BID For COD today
Beron, Cuenco 25 term cephalic RBC 4.11 3.82 Ca+Vit.D BID Daily Perineal hygien
live baby boy
WBC 5.92 10.58 Maintain abdominal b
8/23/16 G2P2 with good
Neu 74.6 91.3 TCB on 9/6/16
outcome
O+ Lym 15.5 3.7
Mon 8.8 4.9
Eos 0.8 0.1
Plt 235 218

UA 8/23
Color Light Yellow
Characteristic Slightly turbid
Reaction 6.5
SG 1.010
Sugar Negatve
protein Negative
RBC 0-1
WBC 1-3

0 2016053313 ADEVA, Kaily G1P0 39 1/7 Induction of Lab PACU

6 18 weeks AOG by
Dr. Madera LMP
Preeclampsia,
8/25/2016 G1P0 Sever
BP
0 2016013994 SILACAN, G4P3 (3003)PU For repeat CS IV & CBC 8/24 Tranexamic acid 1 gm IV O2 at 3 lpm
7 Rowena 36 4/7 wks AOG BTL Hgb 11.4 Q8 x 24 hrs
Dr. Bernardino by LMP; in Hct 33.8 Paracetamol 900mg IV Q8
42 beginning labor RBC 3.79 RTC
8/24/16 Vit K 10mg IV Q8 x 2 more
WBC 11.95
G4P3 doses
Neu 56.3
Lym 35 Salbutamol nebule
O+
Plt 266 Cefazolin 1 gm IV OD
 UA 8/23
Color Yellow
Characteristic Slightly turbid
Reaction 7.0
SG 1.025
Sugar Negatve
protein Negative
RBC 0-2
WBC 0-1
0 2016063649 BALLENTE, G6P4 (4014) PU G6P4 (4014) PU For BP Control Cefuroxime 750 mg IV Q8 x GLEMCD with Cracker
8 Florence 31 4/7 weeks 31 4/7 weeks CBC 8/19/16 8/20 8/21 8/22 8/23 8/24 1more dose then shift to LSLF diet this PM L
Drs. Gamboa/ Halim, Cartagena/ Gadin/ QUIMBA/ Gutierrez/ AOG by LMP, AOG by LMP, Cefuroxime 500 mg/tab, tab BIDx diet once with BM
Preeclampsia Preeclampsia Hgb 12.1 10.2 11.5 11.9 11.1 11.6 7 days
Montemayor 34 IVF: Oxytocin drip to
Severe Severe Hct 36.9 31.9 36.0 36.4 33.5 35.5 Paracetamol +tramadol tab 1 tab consume continue
8/17/16 B+ Q8 prn for pain MgSO4 drip to com
RBC 4.27 3.70 4.10 4.23 3.94 4.10 MV tab OD 24 hours
WBC 11.99 10.52 13.31 14.54 17.00 16.0 FeSO4 tab BID Labs: Follow up Repea
5 Ca+Vitamin D tab BID for TPAG
Neu 79.2 56.1 66.6 69.8 84.7 73.5 Amlodipine 10 mg/tab OD
For COD on day 3 postop
Lym 18.1 31.3 21.9 20.6 7.7 18.5 Maintain tight abdominal binder
Bas 0.3 0.8 0.6 0.3 0.2 0.1 10. Daily Perineal hygiene

Mon 2.2 10.3 9.2 9.0 7.4 7.9

Eos 0.2 1.5 1.7 0.3 0.0 0
Plt 274 293 337 258 147 83

8/19 8/21 8/22 8/23

24h 2009.10mg/24hr 2009.10
urine
CHON
SGPT 189 264.60 303.10 298.10 226.30
LDH 620 532 636 673.00 587

8/17 8/19 8/21 8/22 8/23 8/24

Crea 69 63 71 75 98 105

Urine GS (8/22): unremarkable

9 2016056047 ODULIO, Endometrioid 1. Cefuroxime 1.5 g IV 30 NPO post Midnight
Corazon Adenocarcinoma, minutes prior to OR IVF D5LR 1L x80 once
Endometrium, 2. Omeprazole 40 mg IV Bowel Prep
Dr. Bagadiong 68/F confined to the OD
Fleet Enema at 8 pm
corpus, S/P
Cleansing Enema at 4
Endometrial
Biopsy Secure consent for EL
EHBSO BLND on 8
Secure 2 units whole
Properly typed and
crossmatched

Anestghesia NOtes
NPO post midnight
Omeprazole 40 mgIV
once

1 2016002061 BOLLER, G2P1 (1001) PU G2P2 (2002) PU For LTCS s/p LTCS I CBC 8/22 8/23 Cefalexin 500 mg/tab 1 tab Q6x 7 LSLF diet
2 Rosalie 38 weeks AOG term cephalic secondary to Hgb 11.7 10.9 days MGH once cleared by
Drs. Bernardino/Locaylocay/Gadin/Quimba/Donato, Guterrez by early UTZ, delivered to a prolonged 2nd Hct 35.5 34.1 Paracetamol + Tramadol tab 1 tab endo for Clearance
38/F overt DM, Hepa live term baby stage of labor, RBC 4.23 3.92 Q8 Prn for pain to discharge
8/22/16 B Reactive girl via LSCS I, failure in MV tab OD
WBC 9.43 22.95
G2P2 preeclampsia descent FeSO4 tab BID
Neu 70.4 93.4
severe, overt DM, (8/23/16) Ca+vitamin D
A+ Hep B reactive Lym 22.5 3.5 MV tab OD
Mon 5.7 3.0
Eos 1.1 0
Plt 322 327

UA 8/22
Color Light Yellow
Characteristic Slightly turbid
Reaction 6
SG 1.010
Sugar Negatve
protein Negative
RBC 0-1
WBC 1-3
Epithelial Moderate
Bacteria Few

8/23
Na 142.70
 K 3.91
HbA1c 6.6%
FBS 5.07
SGPT 9.50
LDH 177
CREA 79
Eos 2.4
Plt 198
1 2016053792 SANTIAGO, Ovarian New For ex-lap PFC, 1. Cefuroxime 1.5 g TIV 30 OR deferred
3 Zenaida Growth, probably TAHBSO, imprint mins prior to OR cut off
Dr. Quevedo/Cartagena, Malignant cytology of affected 2. Metronidazole 500 mg/tab Soft diet then
Halim/Morante/Quimba/Montemayor, Corpuz 60 ovary, CSS if q6 at MN
malignant, 3. Omeprazole 40mg IV OD
8/24/16 appendectomy if once on NPO
mucinous
1 679352. CORALES, Endometrial Ca Endometrioid For Exlap,Extrafascial CBC 8/26 1. Cefuroxime 500 mg cap BID May have Clear Liquid
4 Elvira Adenocarcinoma Hysterectomy, Hgb 15.1 2. Celecoxib 200 mg cap BID well tolerated then
Dr. Quevedo/Cartagena, Grade 2 Bilatera Hct 45.1 Diet
Halim/Morante/Quimba/Montemayor, Corpuz 66 Endometrium, Salpingooophorectom RBC 4.95 DAT once with BM
Surgical Stage y, PFC, Bilateral Continue IVF
WBC 19.92
8/24/16 O+ IIIC Lymph node disection
Neu 84 Follow up Repeat CBC
S/P Exploratiry
Lym 6.7 Shift IV medications
Laparotomy ,
Extracorporeal Plt 271 May Remove IFC at 1
Hysterectomy , 8/26 For COD tomorrow
Bilateral Salpingo K: 4.03 Encourage early
OOPhorectomy, ambulations
Bilateral Lymph Monitor Abdominal gr
Node Disection Retain IFC
1 2016027960 ADVINCULA, G0, Myoma Uteri Nulligravid, For TAHBSO with S/P TAHBSO CXR: Normal 1. Cefuroxime 500mg IM BID x 7 GLEMCD with cracker
5 Monica Abnormal Uterine imprint cytology of with imprint ECG: Normal sinus rhythm days IVF as ordered
Dr. Carino/Alava/Acosta Bleeding, endometrium cytology of 2. MV tab OD Encourage ambulatio
36/F Leiomyoma, endometrium CBC 8/24 3. FeSO4 BID
Maintain abdominal b
8/23/16 Intramural Hgb 10.3 4. Mefenamic Acid 500 mg/ca[p Q6
VSQ4
prn for Pain
Hct 33.0
5. Metronidazole acid 500 mg/ cap
RBC 3.99 prn for pain
WBC 6.99 6. Bisacodyl suppository per rectum
Neutro 71.4
Lympho 18.6
Baso 0.1
Mono 9.6
Eos 0.3
Plt 305
1 2016025314 DE VERA, G2P1 (1011) G2P1 (1011) For Exlap TAHBSO S/p Exploratory CBC 8/25 Cefuroxime 500mg/tab BID x 7 DAT
6 Virginia AUB-L AUB- Myoma Laparotomy Hgb 12.8 days IVF: Maintain on heplo
Dr. Carino/Alava/Acosta Uteri, with Hct 36.9 Metronidazole 500 mg/tab q6 x 7 Give Bisacodyl supp,
47/F Adenomyosis adhesiolysis, RBC 4.33 days per rectum now
endometrial MV tab OD
WBC 16.7
biopsy FeSO4 tab BID
1
Mefenamic Acid 500mg/ tab 1 tab
Neutro 91.9 Q6 PRN for pain
Lympho 3.9
Plt 265
Crea: 51.00
8/24/16
8/26/16
Na: 138.60
K: 3.14
Creatinine:51
1 2016064916 PONSAL, G1P1 (1001) T/C G1P1 (1001) D Exlap, Bilateral s/p EL S&O R, CBC 8/22 1. Doxycycline 100mg BID 8days GS notes:
8 MARILYN Ovarian New Endometriotic oophorocyctectomy, Oophorectomy Hgb 11.3 2. FeSO4 BID NPO
Dr. Valencia/Joves/Morante, ANGKAWIJAYA/Acosta/Corpuz, Growth, cyst R ovary; possible L (8/21/16) Hct .33.6 3. MV OD Continue Present
Montemayor 31/F Bilateral, Dermoid cyst salphingoopherectom RBC 3.91 4. Omeprazole 40mg TIV OD management
Probably twusted with y 5. Ketorolac drip at 90mg in 250cc Maintain NGT open to
WBC 22.11
8/21/2016 0+ v.s. ruptured endometriotic D5W x 24h monitor output Qshi
cyst L ovary; Neu 89.5 6. Ketorolac 30mg q6 TIV PRN
Lym 4.8 Maintain IFC monitor
ONG bilateral 7. PNSS 90cc + 10meqs KCl
Mon 5.5 Follow up official Plain
@100cc/hr x 2 cycles
Eos 0.0 result
Plt 179 Refer
Blood type O+
Remove NOT and I
UA 8/21 May have CL, GL
Color Dark Yellow To consume ketodr
Characteristic Slightly turbid Encourage Ambula
Reaction 6.5 Continue Present
SG 1.020 Management
Sugar Negatve
protein +1
RBC 40-60
WBC 3-5
Epithelial Few
Bacteria Few
 8/22 8/23
Crea 48.00
Na 140.80
K 2.66
Thromboplastin Time Patient=35 3.28
Control=28

UTZ- 7-12-16
Normal anteverted Uterus
Both Adnexal mass, most likely ovarian in nature

ABDOMINAL XRAY U/S 8/24/16 (INITIAL)

(+) Presacral gas
(-) Dilated bowel
(-) air fluid levels
(-) pneumoperitoneum
T/C Ileus
GYNE-ONCO (9)

20 2016065090 TAN, Estelita SCCA LCNK CERVIX SCCA LCNK CERVIX For medical CBC 8/22 1. Human albumin 25%/ml x8 doses as Problem List
STAGE II B STAGE II B management Hgb 11.4 previously ordered 1. Cervical Cancer
Drs. Bagadiong/Brazal/Soriano/Barcial/Villanueva 79 (correction of Hct 33.4 2. Furoisemide 20 mg/IV every after 2. Hypoalbuminemia
hyponatremia) RBC 3.70 albumin 3. Leukocytosis
8/23/2016 3. FeSO4 4. UTI
WBC 27.51
4. MV OD
Neu 91.4
DAT with 3 eggwhites/meal
Lym 4.5
For NA+
Mon 3.9
For Chest X ray
Eos 0.0
Apicolordotic view
Plt 563
VSQ4
Random Urine Sodium: 15 mmol/L
PT: 14.4/13.4/1.09/87
ECG: Sinus Tachycardia
PT: 1.09
PTT:14.4
8/22 8/23 8/24
Crea 50.0 50.00
Na 119.40
BUN 4.30 4.3
RBS 4.83 4.83
Albumin 21.7 21.70
Cl 87
SGPT 103
SGOT 41.0
K 4.72
21 2015066938 PICACHE, Cervical CA St. III B Adenocarcinoma, For correction of Blood Transfusion CBC 8/23 8/26 1. MV OD DAT
Mary Ann Stage IIIB anemia Hgb 3.6 5.6 2. Tranexamic Acid Maintain IVF
Dr. Bagadiong/Soriano, Brazal/Barcial/Villanueva Anemia Hct 13.6 20.5 3. FeSO4 BID Facilitate Blood transfusion
37 Blood Transfusion RBC 1.99 2.65 4. Tramadol 500mg/tab PRN PRBC transfused)
8/24/16
WBC 17.09 77.4 Facilitate pending Labs
G7P7
Neu 87.9 75.1 Facilitate ECG and Liver
O+ Lym 8.4 15.1 Ultrasound
Mon 7.3 5.4 Continue giving meds
Eos 0.3 3.9
Plt 657 619
Still for

UA 8/23 Repeat CBC post BT of 3 un

Color Yellow Long Term Plan is to Chemo
Characteristic Slightly turbid VSQ4
Reaction 5.5
SG 1.025
Sugar Negatve
protein Negative
RBC 0-2
WBC 3-6

8/26
Na+: 134.7
K: 3.61
BUN: 1.8
ALP:80
SGPT: 9.0

23 2016024792 EVANGELISTA, MMMT MMMT,uterus with For medical CBC 8/23 1. Multivitamins OD MGH after BT
Teresita heterologous management Hgb 10.6 2. Ferrous Sulfate BID Follow up blood CS/ Urine G
Drs: Bagadiong component, stage Hct 31.4 3. Ciprofloxacin 500 mg/cap BID to Complte result
67/F l,S/P EHBSO, BLND, RBC 3.30 7 days Follow up at Gyne OPD on 8
8/23/16 PFC,RPS, S/P
WBC 2.12 Refer accordingly
A+ carboplatin, Paclitaxel
Neu 21.0
IV
Lym 73.0
Mon 6.0
Eos 0.0
 Plt 130

24 2016065689 TANGOG,Christin Immature Cystic For correction of CBC 8/23 8/26 1. Furosemide 40 mg IV with BP Precaution S/P 4units PRBC
e Teratoma, anemia anemia Hgb 4.8 12.8 2. Nephocan 1 can TID Uremic Diet
Dr. Bagadiong severe Hct 14.6 36.2 Limit OFI to <1L/ day
15 RBC 1.79 4.47 IFC and hook to Urine Bag
8/24/16
WBC 7.14 16.08 Pklease Facilitate BT of 1 un
AB+
Neu 85.3 88 Day
Lym 9.9 6.3 For Alkaline Phosphatase
Mon 4.8 5.5 Facilitate Alkaline Phosphata
Eos 0.0 0.1 without fail
Plt 422 296 Repeat Crea
8/26 Follow up Labs
Total Protein: 47.9
Albumin:19.4
Globulin 29
A/G ratio:0.68

8/23/16
Na:114.4
K: 4.25
Crea:3.46

26 2003112833 OCAMPO, Clarita Adenocarcinoma Adenocarcinoma, well For correction of CBC 8/25 1. Cefuroxime 1.5 gm IV 30 minutes prior Soft Diet the NPO
differentiated differentiated, anemia Hgb 8.7 to OR Maitain IVF
Dr. Bagadiong/Brazal/Soriano/Barcial/Villanueva 51 endometrium endometrium Hct 26.9 2. Omeprazole 40 mg IV OD once with NPO Continue Blood transfusion
RBC 3.07 3. Start Tranexamic Acid 500 mg IV Q8 units PRBC
8/25/16 O+
WBC 11.78 For Repeat CBC with 6 hour
Neu 66.1 last BT
Lym 21.2 Follow up HBA1C and FBS
Plt 365 For EL EHBSO, PFC BLND to
case
UA 8/25 For Bowel Prep
Color straw Secure consent for OR
Characteristic Clear Insert CP and anesthesia cle
Reaction < 5.0 For Securing 2unit PRBC for
SG 1.015 possible OR use
Sugar Negatve Full body bath and care
RBC 1-3 For OR as 2nd case
WBC 0-2

27 2015055851 BRONCANO, SCCA, LCNK cervix Squamous Cell For chemotherapy s/p CRT w/ 1. Ranitidine 150 mg IV 1 tab BID 3 days MGH after Chemotherapy
Remedios stage IIIB Carcinoma Cervix Ciplatin VI NED x 2. Metoclopramide 10 mg/tab 1 tab TIDx 3 Labs as OPD Basis
Dr. Bagadiong/Brazal/Barcial/Villanueva Stage IIIB 7 months tumor days Follow up onco OPD on Sept
59 S/P Complete VI recurrence 3. MV tab OD
8/25/16 Tiumor Recurrence 4. FeS04 tab BID
Chemotherapy 5. Vitamin B complex 1 tab TID
28 2016066084 ANANAYO, SCCA, LCK, cervix For corrction of CBC 8/25 Diphenhydramine 1 amp DAT w/ Sap
Caroline stage IV A anemia Hgb 8.3 PT 30 mins prior to BT PNSS 1L x KVO
Dr. Bagadiong/Soriano/ Brazal/Barcial/Villanueva Anemia moderate Hct 26.5 Paracetamol 300 TIV For BT 2 U PRBC
37 RBC 3.36 Still undecided for HD
8/25/16
WBC 26.77
O+
Neu 86.4
Lym 6.8
Plt 419
 GYNE WARD (11)
26 2015042170 MARTIN, Maricel Cervical CA St.IIIB SCCA, LCNK, Cervix, Medical CBC 8/22 Ketorolac 30mg IV DAT , High
St. IIIB, Pelvic management HGB 10.8 q8 protein die
Dr. Bagadiong/Alava/Angkawijaya/ 36 Abscess HCT 35.6 Omeprazole 40mg include 2 e
Beron, Cuenco RBC 4.68 OD wites per m
G3P3 WBC 18.4 Tramadol 50mg IV COD BID, P
8/23/16 NEUT 86.9 Clindamycin 900mg For liver U
A+ LYM 8.5 IV tomorrow
BASO 0.3 Gentamycin 240mg
MONO 4.1 IV
EO 0.2 Tranexamic Acid 1g
PLT 695

UA 8/22
Color RED
Transparency TURBID
pH <5
Spec Gravity >1.030
Sugar -
Protein 2+
RBC >100
WBC 30-40

8/22
BUN 3.89
CREA 55.32
NA 140.4
K 4.02
PT 14.9
ACT 80%
INR 1.15
PTT 24.3
TP 72
ALB 21.30
GLOB 50.7
A/G 0.42
SGOT 23
SGPT 25
ALK 143

GS (urine) 8/24:
Pus cells None found
Epithelial cells None found
Gram negative bacilli None found
Gram positive cocci None found
IC gram negative diplococci None found
EC gram negative diplococci None found

GS (wound discharge) 8/24:

Pus cells None found
Epithelial cells None found
Gram negative bacilli None found
Gram positive cocci Few
IC gram negative diplococci None found
EC gram negative diplococci None found

BLOOD GS 8/25
No grwoth after 24hours incubation under anaerobic condition.

WAB CT 8/23
There is a complex avascular collection with ill defined margins seen in the soft tissue plane of the
infraumbilical region (5.9x3.8x4.5cm, ~52ml) and in the lowerabdomen more on the right
(4.3x5.0x7.1cm,~80ml). intrapelvic extension is also noted. The above findings suggestive of
abscess formation with intraperitoneal extension.

27 2016062792 TURALBA, G9P7 (7025) AUB G9P7 (7025) AUB For correction Endometrial CBC 8/12 8/16 1. FeSO4 BID DAT
Rosalindita T/C Myoma Uteri of anemia biopsy HGB 5.3 12.3 2. Metoprolol 50mg/tab BID For possible discha
Drs: Cole/Joves/Morante,Iskandar/Acosta/ cannot totally rule HCT 18.0 39.4 3. Tranexamic Acid 500mg/tab once w/ official
Corpuz,Montemayor 48 out Endometrial RBC 2.15 4.58 2tabs q6 endometrial bio
pathology 4. MV tab OD result
WBC 10.35 5.49
8/12/16 G9P7 5. Cefuroxime 500mg/tab BID
NEUT 77.3 68.2 x 7 days
LYM 10.0 10.7 6. Azithromycin 500mg/cap
O+ BASO 0.2 0.5 OD
MONO 8.8 14.2
EO 3.7 6.4
 PLT 238 218

UA 8/12 8/17
Color Yellow Light yellow
Transparency Clear Slightly turbid
pH 6.0 7.5
Spec Gravity 1.005 1.015
Protein Neg Neg
Ketone Neg Neg
Sugar Neg Neg
RBC 4-6 15-18
WBC 0-1 0-2
Bacteria None None
Epi cells Moderate Few
Mucus threads Few Few
Amorphous phosphate Few

8/16/16 PT: 13.3

Control: 13.4
INR: 1.00
%: 100
Crea 52
APTT: 27.2
Control 29.6
8/15 TVUS
Enlarged anteverted uterus with endometrial contents as described suggestive of hyperplasia; normal both ovaries
8/16 CXR: Pneumonia, right lobe
Magnified heart versus true cardiomegaly
8/20 Sputum G/S
Pus Cells: <25
Epithelial Cells: >25
Gram (-) bacilli: None Found
Gram (+) cocci: None Found
Intracellular gram (-) diplococci: None Found
Extracellular gram (-) diplococci: None Found
AFB
Pus Cells: <25
Epithelial Cells: >25
AFB: 0
8/20 Sputum C/S
Specimen consitent with saliva unfit for culture
28 2015045487 NABOS, Endometrioid Endometrial For Anemia CBC 8/12 8/14 8/17 8/19 8/21 8/25 1. Omeprazole 40 mg TIV q12 Uremic die
Librada Adenocarcinoma adenocarcinoma, Correction S/P IJ cath 2. Amlodipine 5mg/tab OD For AVF cre
HGB 4.8 7.0 11.9 17.3 14.2 10.1
Drs. Delos Reyes/ Soriano, Brazal/Barcial/Villanueva Grade I Stage 3C2 grade 1 endometrium insertion 3. Tramadol 50 mg TIV q6 for prior to
64 y.o. St. IIIC (LVSI S/P EL, HCT 14.8 21.0 35.6 50.4 40.3 28.9 pain discharge/
8/12/16 PFC, TAHBSO hemodialysis RBC 2.00 2.64 4.41 6.30 5.21 3.69 4. Metoclopramide 1 amp q8 basis
G0 Biopsy of at Fe del TIV For poss H
WBC 12.85 12.99 14.71 11.65 7.42 2.02 5. Paracetamol 300mg IV q4
retroperitoneal mass Mundo Sat.
NEUT 92.5 96.5 94.7 94.5 93.6 83.6 RTC
B+ S/P carboplatin- For cystocl
LYM 3.7 1.3 18.8 2.9 2.8 11.4 6. NaHCO3 50 mEqs SIVP
Paclitaxel VI For transfu
S/P CRT BASO 3.6 0.1 0.1 0.1 0.1 0 5U Plt. Con
MONO 0.2 2.1 3.6 2.5 3.4 5.0 Then for re
CBC w/ PC
EO 0.0 0.0 0 0.0 0.1 0 INR, APTT
PLT 252 184 85 45 26 19

8/25
PT 17.1 12
PT Control 13.4 13.4
PT INR 1.35 1.00
PT % 64 100
Activity
APTT 24.7
APTT Control 32.4

8/17 8/21 8/25

BUN 35.90
Creatinine 826 846.00 586.00 214
SGPT (ALT) 13.10

ABG 8/13 8/17 8/19

pH 7.25 7.15 7.23
pCO2 13.7 15.2 12.4
pO2 177.3 90.2 141.4
HCO3 5.9 5.2 5.1
BE -18.3 -21.3 -19.4
O2 99.0 94% 98.5

UA 8/12/16
Color Yellow
Transparency Turbid
 pH 6.0
Spec Gravity 1.015
Protein 3+
Ketone Negative
Sugar Negative
RBC 1-2
WBC >100
Bacteria moderate
Epi cells Few
8/20: Blood GS/CS(left median) : no growth after 5-days incubation under aerobic condition
8/18: Blood GS/CS(right arm): Light growth of Pseudomonas aeruginosa
CXR initial reading: IJ catheter in place with tip at T9 level; minimal densities seen at bibasal
lung fields suggestive of pneumonia
8/15: HBsAg nonreactive

29 889577 OANDASAN, Cervical CA St. IIIB For medical CBC 8/23 1. Tramadol 50mg TIV q8 PRN PROBLEM LIST
Janeth management Hgb 12.1 for pain 1. Cervical CA
Dr. Bagadiong Hct 34.6 2. Tranexamic acid 1g TIV q6 2. UTI
42F RBC 4.21 3. FeSO4 tab BID 3. CKD sec to
8/25/16 4. MV tab OD Obstructiv
WBC 12.0
O+ 5. Ceftriaxone 1g TIV OD uropathy
9
6. Paracetamol 300mg TIV q6 Uremic Die
Neutro 86.6
PRN Limit OFI
Lympho 7.4 7. Paracetamol 500mg tab q4
Baso 0.2 8. Ranitidine 50mg IV
Mono 5.5
Eos 0.3
Plt 365

UA 8/23
Color Red
Transparency Turbid
pH 7.0
Spec Gravity 1.010
Protein 2+
Ketone Neg
Sugar Neg
RBC 3-5
WBC 70-80
Bacteria Many
Epi cells few

Crea 509
K 3.86
31 726330 VILLAR, SCCA Cervical Squamous cell Blood CBC 8/2 8/10 8/13 8/16 8/17 8/18 8/20 8/24 1. N-acetylcystein OD PROBLEM LIST
Jael Cancer Stage IIB carcinoma; large cell Transfusion Hgb 9.6 9.6 7.4 7.2 9.5 9.3 11.6 9.6 2. MV OD 1. Cervical
Drs. Cuenca / Brazal, Soriano / Barcial / non-keratinizing Hct 28.5 29.5 22.4 21.4 28.5 26.9 32.5 27.0 3. FeSo4 OD 2. CKD sec
Villanueva 46/F cervix Stage II-B S/P s/p NT RBC 3.31 3.47 2.6 2.59 3.44 3.26 4.02 3.30 4. Amlodipine 10 mg tab OD Obstruct
CRT with Cisplatin VI, insertion 5. Tramadol 500 mg tab q6 Uropathy
WBC 25.61 20.40 27.92 30.04 25.49 28.52 24.59 16
7/10/16 O+ NEDx7months, Tumor 7/30/16 PRN for pain 3. Anemia
Neutro 88.4 86.7 71.2 89.8 89.2 90.0 89.7 90.4 6. Metoclopromide 10 mg tab
Recurrence (Pelvic 4. t/c HAP
Lympho 5.7 5.8 3.3 4.0 4.9 4.5 5.4 6.4 PRN for vomiting
and Pulmo Mets), S/P IJ Catheter Uremic die
Baso 0.5 0.3 0.2 0.2 0.2 0.2 0.1 0.3 7. Paracetamol 1g IV q8 RTC Limit OFI
Anemia insertion Mono 5.0 6.9 5.0 5.8 5.5 5.2 4.6 2.8 8. Tranexamic acid 500 For poss A
Eos 0.4 0.3 0.3 0.2 0.2 0.2 0.2 0.1 mg/vial 1 gm IV Q6 creation
Plt 288 231 231 363 272 280 211 182 hours - HOLD tomorrow
9. Klyte tab TID x 6 doses Refer to ID
7/19 7/27 8/6 10. HNBB 10mg/tab PRN clearance
PT 15.3 15.4 15.8 11. PipTazo 2.25g IV + 90cc AVF creatio
ONSS x 2h q8 For poss H
PT control 13.4 13.4 13.4
PT INR 1.18 1.19 1.22
% activity 78 77 74
PTT 32.5 32.0
PTT Control 31.3 30.9

8/2 8/7 8/1 8/1 8/1 8/1 8/1 8/2 8/23 8/24
0 3 6 7 8 0
BUN
Crea 94 615 411 487 413 447 335
5
SGP
T
SGO
T
ALP
Na 13
5
K 4.5 5.2 3.3 3.5 3.5
8 7 7 8

07/19/16
Mg : 1.91
Inorganic Phosphorus: 4.3
Ionized Calcium: 1.08
UA 7/14
Color Light yellow
Transparency Slightly turbid
pH 7.5
Spec Gravity 1.010
Protein 1+
Ketone Neg
Sugar Neg
RBC 20-30
WBC 60-70
Bacteria Moderate
Epi cells few

ABG 7/16 8/2

T 37
FIO2 21
PH 7.2 7.16
PO2 148 129.5
PCO2 18 12.3

O2 SAT 99 97.9
HCT 46
HCO3 STD 12.4
HCO3 8.3 4.3

TCO2 9
BE -16.1 -21.6
BE ECF -18.6

THb 14.3
Interpretation Partially compensated
metabolic acidosis;
over corrected
hypoxemia
 Initial CXR (8/2/2016):
PTB, bilateral upper lobes

Specimen: Urine 8/11

Gram stain on direct smear
Pus Few
Epithelial cells None
Gram negative Few
Gram positive none

Uring GS/CS: light growth of Hafria alvei

Blood GS/CS: no growth after 24 hours of incubation

8/17 BLOOD CS:

LEFT ARM: Light growth of E.coli

(7/14/16): HBsAg nonreactive; HCV nonreactive

8/21 KUB UTZ

Bilateral renal parenchymal disease, Grade II with severe pelvocaliectasia
Multiple echogenic foci in the left kidney which may represent nephrolithiasis vs blood clots

32 2016002754 HALILI, Ovarian Cancer Adenocarcinoma Medical SP CTT 1. FeSO4 tab BID DAT
Editha Stage III ovary, stage IIIC rule Management insertion 2. Give Furosemide After BT Refer to TCVS for p
Drs. Delos Reyes/Brazal, Soriano/ Barcial/ Villanueva out IV Correction of s/p pigtail 3. Piptaz 4.5g IV + 90cc PNSS Pleurodesis
55 s/p chemotherapy Anemia insertion x 2hrs q6 For BT 1U BT
8/10/2016 with Cisplatin and 4. Moriamin forte TID
Refer back to Pulm
G3P2 Paclitaxel IV 5. MV OD
UA 8/8 poss. discharge
Color Yellow Pleural Effusion 8/8 8/11 8/24
Transparency Turbid A+ HGB 90 11 9.6
pH 6.5 HCT 0.28 34.9 31.3
Spec Gravity 1.030 RBC 3.05 5.1 4.47
Protein +1 WBC 8.0 9.82 12.9
Ketone 3
Sugar Neg NEUT 0.40 76.5 78.6
RBC 2-4 LYM 0.58 12.1 9.0
WBC 20-25 BASO 0.9 0.5
Bacteria Many MONO 0.02 9.8 11.3
Epi cells Many EO 0.7 0.6
PLT 260 474 539

Liver Function 8/9

Total Protein 5.35
Albumin 1.95
Globulin 3.40
A/G 0.57

Blood chemistry 8/8 8/10 8/15

BUN 4.56
Total Cholesterol 69.8
SGPT 58.9
SGOT 56.0
Na 136.9
K 5.24
Creatinine 38.00

LD in PF 346.0
Glucose in PF 1.57
Total protein in PF 58.80

8/15
PF is reddish, turbid, approximately 15 mL, RBC- 50000/cumm, WBC- 830/cumm, Mononuclear cells- 80%, PMN- 20%
CXR official (8/15):
Regression of pneumonia, right
Pneumonia, bilateral paracardiac regions
s/p drainage tube insertion
Pleural fluid analysis (8/15):
Orange, turbid, approx.. 5 cc, RBC 20,000/cumm; WBC 285/cumm
Pleural fluid CS (8/17): No growth after 48 hours incubation under aerobic condition
33 2016065135 KOH, Edna AUB G5P3 (3023) AUB L, For Correction CBC 8/22 Tranexamic Acid 1g DAT
t/c M; Anemia of Anemia HGB 7.7 IV now then q6 For repeat CBC po
53 HCT 24.8 FeSO4 tab BID BT
Dr. Perez/Locaylocay/Gadin/Quimba/Donato,Gutierrez RBC 2.54 MV tab OD MGH once with no
G5P3 WBC 12.54 CBC
8/22/16 NEUT 83.8 For EM biopsy prio
A+ LYM 10.1 discharge
BASO 0.5
MONO 4.7
EO 0.9
 PLT 193

UA 8/22
Color Yellow
Transparency Turbid
pH 5.5
Spec Gravity 1.025
Protein -
Ketone -
Sugar 1+
RBC >100
Pus cells 5-10

8/22
Crea 63.00
Sodium 142.9
Potassium 4.07

TVUS (8/23/16): whole uterus is converted to huge myomatous mass measuring 27.8x16.4x18.3cm
with ill-defined myometrium

34 2016066092 ALVAREZ, Nulligravid t/c AUB- For correction CBC 8/24 1. FeSO4 tab BID DAT
Geraldine O; Anemia Severe of anemia HGB 7.7 2. MV cap OD For BT 4U pRBC
Dr. Madera/Halim, Cartagena/Morante/Quimba/ HCT 24.3 3. CEE 0.625 mg 4 For repeat CBC po
Corpuz, Montemayor 16 RBC 2.99 tabs q6 BT
4. Mefenamic Acid
WBC 5.34 O2 at 2-3LPM via N
8/25/16 G0 500mg cap q8
NEUT 58.2 5. Diphenhydramine 1
LYM 30 amo TIV 30 mins
O+ BASO 0.2 prior to BT
MONO 10.1
EO 1.5
PLT 495

UA 8/24
Color Yellow
Transparency Slightly
Turbid
pH 6.00
Spec Gravity >1.030
Protein Neg
Sugar Trace
RBC 30-40
WBC 3-4
35 2016061427 VILLANUEVA, Cervical CA stage lll Squamous cell For Medical s/p IJ catheter CBC 8/14 8/17 8/17 8/20 8/21 8/24 Ceftriaxone 1g IV Uremic diet with S
Emma B cancer, LCNK Cervix Management insertion (8/18) HGB 94 5.6 5.9 8.7 8.8 8.3 Q12 1L OFI/day
Dr St IIIB Uremic HCT 0.29 17.7 18.3 25.8 26.9 24.7 MV OD Secure 2U pRBC
Delos Reyes/ Brazal/ Sriano/ 47 encephalopathy; CKD Hemodialysis RBC 3.8 2.26 2.26 3.10 3.19 2.97 FeSO4 + FA BID Refer to RADONCO
barcial/ Villanueva secondary to at Fe del WBC 20.0 15.65 17.84 17.25 21.38 16.4 Tramadol 50mg IV ERBT
B+ Hepa B reactive Obstructive uropathy Mundo NEUT 0.80 78.4 82.6 85.7 87.8 81.8 q8 PRN For cystoclysis
08/15/16 LYM 0.12 11.5 9.5 4.9 4.4 7 Amlodipine SAVE LEFT ARM
BASO 0.00 0.3 0.3 0.4 0.4 0.4 10mg/tab OD
MONO 0.60 6.5 5.9 6.6 7.2 8.4 Omeprazole
EO 0.02 3.0 1.7 2.4 0.2 2.4 40mg/tab OD 30
PLT 206 187 207 209 176 115 mins prior to
breakfast
EPO 4000 q6 podt
UA 8/12 8/15
hemodialysis
Color Amber Red
Carvedilol 6.25
Transparency Turbid Turbid
mg/tab BID
pH 8.00 6.5
Tranexamic acid
Spec Gravity 1.015 1.015
500mg/tab q8 prn
Protein ++ 3+ for vaginal bleeding
Ketone - 1+ Metoclopromide
Sugar - Neg 10mg IV q8
RBC >100 <100 90cc D5W + 10mg
WBC >100 10-20 Nicardipine x
Bacteria Many Few 10mgtts/min to
Epi cells modrate Few titrate by
5mgtts/min
8/11 8/14 8.15 8/16 8/17 8/17 8/21 PipTazo 2.25g + 90
BUN 9.40 cc PNSS
Azithromycin
Crea 415 827 1195 1323 892 500mg tab OD
Na 134.8 140 139.8 142.7 Metronidazole
0 500mg cap q8
K 2.91 3.87 3.25 4.28
Phosp 6.07
iCa 1.21
ALP 79.32 30.9
 ALT 26.7

HbSAg: REACTIVE
ANTI- HBs: NEGATIVE
ANTI- HCV: NEGATIVE
Liver UTZ: ultrasonically normal liver, indidentaly, hydronephrosis of the right kidney
ECG: Sinus Rhytem/ Normal Axis/ Nonspesific ST-T wave changes

8/17
PT time 14.8
PT Control 13.4
PT INR 1.13
PT % 83
APTT 22.9
APTT Control 30.3
CT 230
BT 200

ABG 8/15
PH 7.37
PO2 74.0
PCO2 31.7
O2 SAT 94.8
HCO3 18.3
BE -5.6
Fully compensated metabolic acidosis; mild hypoxemia
36 2016065599 CARRANZA, G1P1 (1001) PAM For abdominal CBC 8/23 1. Diphenhydramine 1 Soft diet
Nora t/c Ovarian New status HGB 7.9 amp/IV 30 mins Still for BT 2U pRB
Drs. Valencia/ Alava/ Angkawijaya/Acosta/ Beron, Growth benign; monitoing HCT 26.1 prior to BT Still for FBS, SGOT
Cuenco 46 Myoma Uteri RBC 4.01 Continue abdomin
WBC 15.9 status monitori
8/24/16 9
O+ NEUT 71.8
LYM 18.0
BASO 0.3
MONO 9.3
EO 0.6
PLT 963

Crea (8/23) 69
Na (8/24) 135.6
K (8/24) 3.88

UA 8/25
Color Yellow
Transparency Slightly
Turbid
pH 7.00
Spec Gravity 1.015
Protein -
Sugar -
RBC 3-5
WBC 0-1
37 2016065639 CASTRO, Lolita Cervical Cancer SCCA, cervix, Stage For Blood HBsAg : negative 1. Diphenhydramine 1 Uremic diet
Stage IIIB IIB; CKD 2 transfusion Anti-HBs : REACTIVE amp 30 mins prior Heplock
Drs. Bagadiong/ Soriano 57 Obstructive Uropathy; Anti-HCV : negative to BT For reinsertion of I
Anemia 2. MV tab OD
8/23/16 CBC 8/25 3. FeSO4 tab BID
O+ 4. Furisemide 40mg IV
HGB 5.7
post BT with BP
HCT 17.2
precaution
RBC 2.11 5. Clonidine 75mcg SL
WBC 22.6 PRN
4 6. Tranexamic Acid 1g
NEUT 93.1 IV PRN
LYM 2.9
BASO 0.3
MONO 3.8
EO 0.1
PLT 264

PAY WARD (5)

PW 2016059921 REGALA, G3 P3 (3003) for TAHBSO S/P TAHBSO Cefuroxime 1.5g TIV as Loading dose DAT
I Mary Ann Multiple Myoma Awaiting CBC post OR ANST then 750mg IV q8 S/P TAHBSO with imp
41 Dra. Perez Uteri cytology
13 47 8/23 EBL: 900cc
A 8/23/16 PT 12.4 For repeat CBC post
PT control 13.3
 PT Activity 117
PTT 27.9
PTT control 28
INR 0.91
CT
BT
Na 145.7
K 4.13
Crea
BUN
FBS

CBC 7/23 UA 7/23

Hgb 9.6 Color Light yellow
Hct 0.34 Characteristic Sl. Turbid
RBC 5.10 Reaction 6.0
WBC 7.64 SG 1.020
Neutro 61.1 Sugar Negative
Lympho 27.7 Protein Negative
Baso 0.8 RBC 3-6
Mono 6.3 WBC 10-15
Eo 4.1 Bacteria Many
Plt 412 Epithelial Few

CT 230
BT 200

ECG
CXR
PW 2016052256 SANTOS, Elyza ONG probably For EL, s/p exploratory 7/18 UA 7/18 1. Cefazolin 1g TIV q8hrs for 3 doses- Soft Diet then DAT on
II Nae Benign Oophorocystectom laparotomy, Hgb 13.0 Color Light yellow completed with BM
42 Dr. Valencia y, Left oophorocystecto Hct 0.42 Characteristic Hazy 2. Vit C OD Continue Oral meds
05 18 my, left, under RBC Reaction 5.0 3. FeSO4 OD Daily perineal hygien
8/22/16 spinal anesthesia 4. Diclofenac 100mg tab q6
WBC 7.8 SG 1.020 Prepare discharge
A+ 5. Cefalexin 500mg q6 x 7days
Neutro 0.71 Sugar Negative summary
Lympho 0.22 Protein +1 For possible discharg
Baso RBC 6-8 tomorrow
Mono 0.05 WBC Over 100 Encourage early
Eo 0.02 Bacteria Many ambulation
Plt Epithelial Moderate VS q4

7/18
PT 12.7
PT control 13.1
PT Activity 99.7
PTT 34.3
PTT control 32.4
INR 0.97
CT 150
BT 240
Na 140.2
K 4.3
FBS 4.5

CXR (8/22/16): essentially normal chest findings

PW 2016065697 SERRANO, Nulligravid, Vulvar Nulligravid, Vulvar For Evacuation of S/P evacuation of CBC 8/23 1. Co amox 625mg/tab BID x 7 days DAT
I Eunice Hematoma Right Hematoma Right labia hematoma hematoma and Hgb 15 2. Mefenamic Acid 500mg q6 Continue oral meds
Dr. Valencia labia secondary to secondary to straddle repair under Hct 45.3 3. Vitamin C 500mg/tab OD Daily perineal hygiene
22/F straddle injury injury spinal anesthesia 4. Perilight x 15mins TID
RBC 5.11 Warm compress BID
8/23/2016 5. Celecoxib 250mg/tab BID PRN for
WBC 14.74 MGH with complete me
B+ pain
Neutro 84.0 Co-Amox 625mg/tab 1
G0 Lympho 9.4 x 7days
Baso 0.3 Vit C OD
Mono 5.6 Mefenamic acid 500mg
Eo 0.7 for pain
Plt 355 OPD follow up after 1 w
BLOOD TYPE B+ VS q4
PW 2016066402 YANGA, Lina G2P2(2002) AUB For EL, PFC, CBC 8/25 NPO post midnight
1 LM ; Impending TAHBSO, FS of Hgb 9.1
Dr.Alcalde 45/F ovarian cyst endometrium, CSS Hct 27.6
40 rupture if malignant Cefuroxime 1.5g IV 30mins prior to OR IVF: D5LR 1L x 30gtts/m
RBC 2.79
11 8/25/16
WBC 6.45
G2P2 Omeprazole 40mg IV OD For possible direct EL,TA
Neutro 71.5
Lympho 19.2 this afternoon
Baso 0.3
Mono 7.9 Still for clearance from
Eo 1.1
Plt 363 Facilitate BT of 1 u PRB

8/25
 PT 14.3 Pre BT med
PT control 14.0
PT Activity 98 Bowel Prep
CT 400
BT 230

8/25
Crea 52
BUN 2.70

Na 138.2
K 3.83

UA 8/25
COLOR Yellow
TRANSPARENCY Clear
RBC 0-1
PUS CELLS None found
CRYSTALS None found
BACTERIA None Found
EPI CELLS Many
PW 2016028855 BARTOLO, Luz Leiomyosarcoma For blood s/p cystoscopy, DJ 1. Atorvastatin 20 mg tab ODHS Uremic diet
II recurrent disease, transfusion stent insertion, CBC 8/11 8/16 8/19 8/22 8/25 2. Trimetazidine 35 mg tab BID Maintain Heplock
42 Dr. Delos Reyes 54 SCCA, LCNK, cervix, left; replacement, Hgb 13.4 11.8 11.2 10.7 9.4 3. Tranexamic acid 500mg/tab TID Refer back to IM pulmo
15 Stage IB I,s/p right (8/15/16) Hct 41.0 36.4 33.3 33.3 28.7 4. Carvedilol 6.25mg/tab; tab BID CXR and Blood CS r
C 8/9/2016 AB+ Radical RBC 4.96 4.36 4.09 3.97 3.43 5. FeSO4 10 mg tab Q6 and poss clearance
Hysterectomy 6. MgSO4 10 mg 1 tablet TID chemo
WBC 14.0 19.2 18.27 19.42 17.28
Bilateral 7. Paracetamol 500 mg tab Q6
Neutro 85.6 79.4 77.6 77.4 79.6 For Chemo with PID
Salpingooophorecto 8. Combivent neb q8 PRN for DOB
Lympho 7.1 10.9 12.8 11.2 8.8 IVF: D5W 1L + Vit B x 8
my, BLND 9. Piptazo 4.5g IV + 90cc x 2hrs q6
(2/6/08,EAMC) s/p Baso 0.2 0.3 0.3 0.3 0.4 10. Pregabalin 50mg ODHS IVF to follow: D5W 500c
Pelvic External- Mono 6.6 8.9 6.6 7.2 8.1 60mg PID
Beam Radiation Eo 0.5 0.5 2.7 3.9 3.1 Premeds prior to PID
Therapy, 2008. NED Plt 286 320 381 480 447 Ondansetron 5mg SIV 2
x 8 yrs, s/p EL, Prior to PID
excision of pelvic UA 8/11 Dexamethasone 8mg IV
mass (4/17/16) prior to PID
Color Yellow Ranitidine 80mg IV 30m
Characteristic Clear rpior to PID
Reaction 6.5 Shift to heplock post ch
SG 1.010
Sugar Negative -IM Cardio-
Protein +1 Continue atorvastatin,
RBC 0-2 trimetazidine, Carve
WBC 42-45 -IM Pulmo-
Bacteria few WOF DOB and Desat
For repeat CBC
Epithelial few
No objection for Chemo
Complete Pip-Tazo up to
8/9 8/10 8/13 8/16 8/19 8/20 8/ days
Crea 231 172 198/1 77 71.00 -Uro-
42 replacement of IFC don
Na 136
K 4.17 3.28/
3.81

8/22
CT 400
BT 220

8/22
PT 14
PT control 13.3
PT Activity 90
PTT 24.5
PTT control 28
INR 1.07

ABG 8/17
pH 7.34
pCO2 34.8
pO2 43.1
HCO3 18.4
BE -6.4
O2sat 76.7
 Lumbosacral Spine X-Ray 8/11:
S/P Ureteral stenting
Ill defined calcific densities right emiabdomen at the level of L1-L2 vertebral bodies.
Nephrolithiasisis evident.
Suggest ultrasound correlation for further evaluation
CXR 8/15:
Pneumonia, bibasal

CXR 8/24: Essentially normal chest finding; old fracture deformity,right 6 th and 7
ribs
Urine G/S 8/13:
Pus Cells: +1
Epithelial Cells: None Found
Gram (-) bacilli: None Found
Gram (+) cocci: None Found
Intracellular gram (-) diplococcic: None Found
Extracellular gram (-) diplococcic: None Found
Urine C/S 8/15:
No growth after 48 hours incubation under aerobic condition
Blood CS 8/19:
Light growth of Staphylococcus hominis spp hominis

ISOLATION (2)
ISO 2016065442 PALMA, Endometrial For medical Piptaz 4.5 grams TIV + 90cc DAT w/
Conchita Cancer management CXR (8/24) : Consolidation Pneumonia, Left ; Apicopleural PNSS x 2hrs q6hrs SAP
Dr. Dr. Cuenca Prev Pulmo thickening, bilateral Azithromycin 500ng/tab OD Facilitate
TBV Combivent Neb, 1neb q8hrs BT 1 more
8/23/2016 CBC 8/23 FeSO4 BID unit PRBC
Hgb 8.7 MV OD Rpt CBC
O+ Hct 28.6 6hrs post
RBC 3.27 BT of 2nd
WBC 16.29 unit PRBC
Neutro 91 Give
Furosemid
Lympho 2.8 e 20mg
Baso 0.1 TIV post
Mono 6 2nd unit
Eos 0.1 with BP
PLT 244 precaution
-IM Pulmo-
Repeat
CXR PAL
ABG 8/23 Rpt ABG
pH 7.36 Sputum
GSCS
pCO2 48.7
Sputum
pO2 38.7 AFB 2x
Blood CS 2
HCO3 27.0 sites
BE 0.9 Cont Pip
Tazo and
O2 Sat 70.6%
Azithromy
Respiratory Acidosis cin
Fully Compensated Cont Neb
Unorrected Hypoxemia q8
Maintain
O2 at
UA 8/23 2LPM via
COLOR Yellow nasal
TRANSPARENCY Clear cannula
RBC 0-1
PUS CELLS 0-2/hpf
CRYSTALS None found
BACTERIA many
EPI CELLS Few

8/23
PT 13.4
PT control 13.4
PT Activity 100
CT 330
BT 300

8/23
Crea 38
SGOT 57 (H)
SGPT 37
Na 138.0
K 2.40

CXR PA/L (8/4)

 PTB, right upper lung, activity undetermined
Pneumonia, right base and left mid to lower lung fields
ECG 8/23/16 Normal sinus rhythm
non specific ST ewave changes V1-V2
ISO 2016055888 BORJA, Leiomyoma Medical CBC 8/25 Diet: DAT w/ SAP
2 Romula Management Hgb 10.6 IVF: D5LR 1L x 30gtts/min
Drs. Hct 34.0 Labs:
61/F RBC 3.62 CBC, UA, ABO Rh, Na, K, Crea
BUN, Pt,PTT, CT,BT, CXR, 12L
WBC 5.26
8/25/16 ECG, FBS
Neutro 42.7 For abdominal status monitoring
Lympho 46.4 Monitor VS q1 and record
Baso 0.2 Daily perineal hygiene
Mono 8.2 Transfer to isolation
Eo 2.5
Plt 392

8/25
PT 13.3
PT control 13.4
PT Activity 100
CT 300
BT 200

8/25
Crea 55

UA 8/25
COLOR Straw
TRANSPARENCY Slightly Turbid
RBC 20-30
PUS CELLS >100
CRYSTALS Amorphous
urates moderate
BACTERIA Few
EPI CELLS Moderate

FSW (1)
40 2015028177 BRIOL, Aspiration For Tracheostomy CBC 8/14 1. Cefepime 2g IV q8 For NST BID
Christine Pneumonia c/o GSA Hgb 12.9 2. Dexamethasone 6mg IM Continue oral fluid
Drs. Bernardino/Joves Cerebellar Hct 41,9 q12 IVF: D5NSS 1L 30 gtts/min
Hemangioblasto For NST TID 3. Progesterone 200mg/gel, 1
RBC 5.05 Monitor FHTQ1
28/F ma gel /vagina BID
WBC 23.62 Follow up official CXR
S/P VP Shunt 4. FeSO4 tab BID
Neutro 88.1
insertion 5. MV cap OD
Lympho 5.5 6. Onima tabBID
O+ Baso 0.2 7. Combivent neb Q8
Mono 6.0 8. N-Acetylcysteine neb Q8
Eo 0.2 9. Cefepime 2g IV +80 CC to
Plt 579 run 1hr Q8
10. Discontinue Omeprazole
ABG 8/14 8/22 11. Start lactulose 30cc ODHS
12. Start bisocodyl rectal
pH 7.35 7.38 suppository once no BM, 1
pCO2 41.6 42.3 cap OD

pO2 226.3 124.3

HCO3 21.4 24.9

BE -4.3 -0.2
O2 Sat 99.4% 98.4%
Metabolic Acidosis Normal Acid-Base
Fully Compensated Balance
Over Corrected Hypoxemia Over corrected
hypoxemia

Blood 8/16 8/22

Chem
Na 136.5
K 3.01 3.96
Albumin 2.53

ETA G/S (8/16):

Pus Cells: +1
Epithelial Cells: Few
Gram (-) bacilli: None Found
Gram (+) cocci: None Found
Intracellular gram (-) diplococcic: None Found
Extracellular gram (-) diplococcic: None Found
ETA G/S (8/18/16) FINAL:
No growth after 48 hours of incubation

Blood CS (8/16/16): initial report:

Left hand-No growth after 24 hours of incubation
Right hand-No growth after 24 hours of incubation

Blood CS (8/20/16): initial report:

Blood right and left: NO GROWTH after 5days incubation under
aerobic condition