Total Number of patients: 5
Main: 3
Co-managed:
Referrals: 1
Admissions:
Discharged:
Expired:
DAMA:
Transferred: / Main:
Admitted:
Co-managed:
Referrals:
Discharged: / Total Number of patients: 2
Main: 2
Co-managed:
Referrals:
Admissions: 1
Discharged: 2
Expired:
DAMA:
Transferred: / Main:
Admitted:
Co-managed:
Referrals:
Discharged:
DAMA: / Total Number of patients:5
Main: 0
Co-managed:
Referrals: 4
Admissions: 1
Discharged:
Expired:
DAMA:
Transferred: / Main:
Admitted:
Co-managed:
Referrals:
Discharged:
DAMA:
Expired:
HEMA: MAIN
PATIENT / DIAGNOSIS / MEDICATIONS / LABORATORIES/ANCILLARIES / PENDING / REFERRAL205B
Suva, Narlyn B.
23/F
DOA: 9/28/10
CC: throat pain and difficulty of swallowing
CIC: Angie
Alt: Christine/Irish
Hosp No.: 06-88-49
Adm No.: 10I00658 / AML s/p re-induction chemotherapy with doxorubicin and cytarabine (9/16/10)
t/c Oral Candidiasis
Febrile Neutropenia / Cefepime 2g/IV q8
Fluconazole 200mg/cap 1 cap OD
G-CSF 300ug/SC OD
Paracetamol 500mg/tab for T≥38C / 9/29 CXR initial read: nodular density seen at the right lower lobe which may be nipple shadow. Suggest repeat CXR with nipple markers. Otherwise unremarkable.
9/29 BUN 6.84, crea 0.37
9/29 CBC: hgb 69, hct 0.20, plt 40, wbc 0.40, neu 0.14, ANC 56
9/28 UA: yellow, slightly turbid, pH 9.0, sp. Gr. 1.015, albumin (-), sugar (-), rbc 0-2/hpf, pus cell 3-6/hpf, sq cell ++, renal cell few, bacteria +, amorphous phosphate +
9/27 CBC: hgb 98, hct 0.26, plt 17, wbc 0.70, neu 0.27, ANC 189
9/27 SGOT 10.01, SGPT 12.23 / For repeat CBC 9/30/10 am. / ID
205A
De Guzman, Jocelyn B.
25/F
DOA: 8/26/10
CC: fever
CIC: GV
Alt: Joyce/Jae
Hosp#: 05-35-16
Adm#: 10H00608 / Admitting diagnosis:
ALL pre-B cell
Working diagnosis:
ALL pre-B cell
HCAP, resolved
GTC Seizures, prob due to Leptomeningeal Carcoinomatosis / Hydoxizine 10mg/tab 1 tab ODHS
Essentiale forte TID
Dexamethasone 4mg/IV
Decrease Dexamethasone 4mg/tab 2 tabs at bf & 1 tab at dinner
Allopurinol 300mg/tab 1 tab OD
NaHCO3 650mg/tab 1 tab TID
Esomeprazole 40mg/tab 1 tab OD
Amlodipine 10mg/tab OD
Keppra 500mg/tab 1 tab BID
Nystatin Swish & Swallow BID
Hyper CVAD regimen: D6
Dexamethasone 4mg/tab 2 tabs at bf 1 tab at dinner
Nystatin, swish and swallow, gargle BID / 9/29: CBC with plt – hgb 106, RBC 2.90, hct 0.30, MCV 104.1, MCH 36.4, MCHC 35.0, RDW 17.1, MPV 8.5, plt 10, WBC 0.30, neutrophils 0.10, segmented 0.10, lymphocytes 0.83, monocytes 0.03, eosinophils 0.04
9/28: CBC with plt – hgb 109, RBC 2.97, hct 0.31, MCV 103.9, MCH 36.7, MCHC 35.3, RDW 16.7, MPV 8.8, plt 40, WBC 0.30, neutrophils 0.07, segmented 0.07, lymphocytes 0.89, monocytes 0.03, eosinophils 0.01
9/27: CBC with plt – hgb 127, RBC 3.53, hct 0.35, MCV 100.3, MCH 35.9, MCHC 35.8, RDW 16.9, MPV 7.9, plt 71, WBC 0.30, Neutrophils 0.16, Lymphocytes 0.81, monocytes 0.03
9/25 MRI with Contrast Initial: Small subcortical metastasis, (+) premature hemorrhage on FFE, (+) gray white matter cortical enchancement, subcortical parenchyma, multiple
9/24 CBC Hgb 136 RBC 3.71 Hct 0.39 MCV 105.30 MCH 36.50 MCHC 34.70 RDW 17.30 MPV 7.10 Plt 69 WBC 1.50 Neu 0.74 Seg 0.74 Lymph 0.26
9/21 Na 137.00 K 3.56 Mg 2.14 iCa 1.14
9/21 CBC hgb 130 rbc 3.63 hct 0.37 mcv 102.70 mch 35.90 mchc 34.90 rdw 17.50 mpv 7.4 plt 150 wbc 3.60 neutro 0.77 lympho 0.23 1 nucleated rbc per 100 wbc
9/20 Cbc Hgb 138 RBC 3.83 HCT 0.39 MCV 102.80 MCH 36.00 MCHC 35.10 RDW 17.90 MPV 7.10 PLT 250WBC 8.80 NEUTRO 0.53 META 0.02 BANDS 0.02 SEG 0.49 LYMPHO 0.38 BLAST 0.08 MYELOCYTES 0.01
9/17 CBC Hgb 137 RBC 3.75 Hct 0.41 MCV 107.8 MCH 36.5 MCHC 33.9 RDW 17.60 MPV 7.10 Plt258 WBC 6.30 Seg 0.55 Bands 0.02 Metamyelocyres 0.03 Lymph 0.31 Blast 0.07 Myelocytes 0.02 3 nucleated RBC/100 WBC seen
9/17 Crea 0.51 AST 169.59 ALT 522.17
9/5 CBC Hgb 99, Hct 0.29, RBC 2.68, Plt, 180, WBC 2.60, Seg 0.67, Lymph 0.33 MCV 109.60 MCH 36.90
9/1 Repeat CBC Hgb 104, Hct 0.31, Plt 238, WBC 2.00, Seg 0.55, Lymph 0.45
8/29 CBC Hgb 111, RBC 3.03, Hct 0.33, MCV 109.90, MCH 36.60, MCHC 33.30, RDW 20.80, MPV 7.80, Plt 258 WBC 1.40 Seg 0.53, lymp 0.46, eo 0.01
8/29 7:30pm ABG pH 7.449,pCO2 30, pO2 88, HCO3 20.8, O2Sat 97%, P/F 200, dFiO2 41
8/29 8am ABG pH 7.469,pCO2 31.6, pO2 46.2, HCO3 23, O2Sat 85%, P/F 165, dFiO2 45.61
8/29 ECG: sinus tachycardia
8/28 U/A pH7.0, SpGr1.005,Alb(-),Sugar(-),WBC2-4/hpf,Sq. Cells few
8/26 CBC Hgb 119, RBC 3.22, Hct 0.36, MCV 110.50, MCH 37.0, MCHC 33.50, RDW 21.30, MPV 8.10, Plt 239 WBC 1.80 Seg 0.36, lymp 0.64
8/26 Crea 0.42, SGOT 116.75, SGPT 315.66
8/26 CXR: follow-up CXR since 7/17/10 shows partial clearing of pneumonic process in the right lower lobe; heart not enlarged; diaphragm, sinuses intact / Repeat CBC / Pulmo
ID
205F
RODRIGUEZ, Chester P.
21/M
DOA: Sept 27, 2010
CC: generalized weakness
CIC: TAL
Alt: binx/Steph
Hosp #: 06-33-15
Adm #: 10I00649 / Pre B cell Acute Lymphoblastic Leukemia s/p Induction Chemotherapy Phase (April 2010), Consolidation Phase (June 2010), Interim Phase (July 2010), Reinduction Chemotherapy (Sept 2010) / Meropenem 1 gm/IV TID
Paracetamol 500mg/tab q4 prn for t > 38C
Esomeprazole 40mg/tab OD
CaCO3 500mg/tab 1 tab BID
NaHCO3 650m/tab 1 tab BID
Allopurinol 300mg/tab 1 tab OD
GCSF 300mcg/SC OD
Dexamethasone 5mg/tab TID
Diet: full neutropenic diet / 9/29: CBC: Hb: 121; RBC: 3.42; Hct: 0.35; MCV: 101.10; MCH: 35.30; MCHC: 34.90; RDW: 18.70; MPV: 8.10; plt: 60; WBC: 0.40; neut: 0.65; segm: 0.65; lymph: 0.33; mono: 0.02
9/29: BUN: 18.40
9/28: HIGH SGOT: 248.93; HIGH SGPT: 301.77
9/28: CBC: Hb: 131; RBC: 3.63; Hct: 0.37; MCV: 101.20; MCH: 36.10; MCHC: 35.70; RDW: 19.20; MPV: 7.90; plt: 70; WBC: 0.30; neut: 0.78; segm: 0.78; lymph: 0.21; eos: 0.01
9/27: LOW Na: 131, K: 3.95
9/27: fecalysis: yellowish brown, mushy, veg cell: (+); yeast cell: (+); fat globule: (++); pus cell:15-20/hpf; mucus: (+); parasite: none found
9/26 creatinine: 0.58; LOW sodium: 127.16; potassium: 3.96
9.26 CBC: Hb: 151; LOW RBC: 4.27; Hct: 0.42; MCV: 98.00; MCH: 35.40; MCHC: 36.10; RDW: 18.30; MPV: 8.00; LOW PLT: 120; LOW WBC: 0.50; neut: 0.49; segm: 0.49; lymp: 0.51
205 H
ROXAS, Benjamin C.
53/M
DOA: 9/28/10
CC: dizziness
CIC: BINX
Alt: Tal/Steph
Hosp #: 05-72-52
Adm #: 10I00692 / multiple myeloma / Allopurinol 100mg/tab 1 tab OD
Enalapril 5mg/tab ½ tab OD
Furosemide 40mg/tab 1 tab BID
Spironolactone 25mg /tab BID
Simvastatin 40mg/tab 1 tab ODHS
Kalium durule 4 doses TID
Pre BT medications:
Paracetamol 500mg/tab 30 minutes prior to BT
Diphenhydramine 50mg/cap 30 minutes prior to BT
Diet:
Peptamen 5 sccops in 1 glass TID
<2g Na, <200mg cholesterol
OFI < 1.2L/day / 9/29/10: crea: 0.65; LOW K: 3.49; LOW Na: 132
HEMA: Co-Manage
209DPribdhas,Evelina Batoon
50/F
H: 07-30-00
A: 10I00594
CC: left leg pain and swelling
CIC: GV
Alt: Joyce/Jae / Admitting Dx:
Deep Vein Thrombosis, Left Lower Extremity; r/o Pulmonary Embolism; Myoma uteri
Working Dx:
Deep Vein Thrombosis, Left Lower Extremity; r/o Pulmonary Embolism; Myoma uteri
IDA secondary to 1) Chronic blood loss probably secondary to AUB, secondary to Myoma Uteri, 2) Nutritional deficiency / Unfractionated heparin: 4000 units IV loading dose, 200ml + 10,000 units maintenance dose to run at 18cc/hr
Paracetamol + Tramadol (Dolcet) 1 tab q8 for pain
Pre BT meds: diphenhydramine 50mg/tab 1 tab and paracetamol 500mg/tab 1 tab both 30 mins before transfusion / 9/29: aPTT 78.9s, N control 34.3s
9/29: aPTT 102.4, N control 34.3s
9/28: aPTT 87.3s, N control 34.0s
9/28: aPTT 81.3s, N control 34.0s
9/28: aPTT 72.6s, N control 34.0s
9/27: aPTT 91.4s, N control 34.2
9/27 CBC with plt – hgb 114, RBC 4.59, hct 0.34, MCV 73.4, MCH 24.7, MCHC 33.7, RDW 28.6, MPV 7.1, plt 356, WBC 8.7, Neutrophils 0.76, segmented 0.76, Lymphocytes 0.21, monocytes 0.01, eosinophils 0.02
9/26 aPTT 1PM – 100.3 secs N control 36.1 secs
9/26 aPTT 12AM – 70.9 secs
9/26 aPTT 7 AM 49.8 secs
9/26 CBC with plt: hgb 55, RBC 3.14, hct 0.21, MCV 65.9, MCH 21.2, MCHC 32.1, RDW 26.4, MPV 6.6, plt 441, WBC 14.2, Neutrophils 0.71, Lymphocytes 0.24, Monocytes 0.01, eosinophils 0.04
9/25 aPTT (7pm) 73.3 secs, Normal Control 34.3 secs; aPTT (11am) 79.1 secs, Normal control 34.3 secs
9/25 FBS 75.18 mg/dL Cholesterol 105.21 LOW, Triglycerides 80.11, HDL Direct 14.93 LOW, LDL Direct 61.60 LOW
09/24 aPTT (9:10 AM) 59.5, normal ctrl 34.2; aPTT (10:15 AM) 47.2, normal ctrl 34.2; aPTT (4 PM) 49.5, normal ctrl 34.2; ABO grp/Rh typing- “O” positive in 3 spheres
09/24 ABO group/RH typing and crossmatching- “O” Positive; Reticulocyte count 20, RPI 4; Protein C 78.5, Protein S 21.3; PT 13.6s Normal Control 12.4s, INR 1.1, PT ratio 1.1; aPTT 44.4, Normal Control 349/23 CBC: Hgb 55, RBC 2.93, Hct 0.18, Plt 525, WBC 18.50, Neutro 0.81, Lympho 0.18, Eosino 0.01
ABG: pH 7.515, pCO2 19.5, pO2 122.3, HCO3 15.7, FiO2 21%
Crea 1.01
CXR initial read: Cardiomegaly, atheromatous aorta; incidentally, mild dextroscoliosis of thoracic spine; Pulmonary vasculature within normal; Lungfields clear; Diaphragm and sinuses are intact / *Duplex scan of Both LE
* 2D Echol with Doppler
*Angiogram of Both LE
*FOBT after 3 days / TCVS
Gynecology
Co-Manage:
CV
Referral:
Hema, Rheuma
HEMA: REFERRAL
PATIENT / DIAGNOSIS / MEDICATIONS / LABORATORIES/ANCILLARIES / PENDING / REFERRAL221 H
Retuto, Cornelio Rocero
64/M
10I00486
07-13-34
CC: fever
DOA: September 20, 2010
CIC: Joyce
Alt: GV/Jae / Hospital Acquired Pneumonia, resolving
COPD at risk
ASHD, CAD, s/p NSTEMI, NIF Class III-C / Symbicort 160mg 14.5mg
Levofloxacin 750mg/tab OD
Enalapril 5mg/tab OD
Imipenem 0.5g/IV q6 (Day 4)
ASA 80mg/tab 1 tab OD
Clopidogrel 75mg/tab 1 tab OD
Atorvastatin 80mg/tab 1 tab ODHS
Ivabradine 5mg/tab 1 tab BID
Amiodarone 20mg/tab 1 tab OD
THM
Enalapril 5 mg/tab 1 tab OD
Amiodarone 20 mg/tab 1 tab OD
Atorvastatin 80mg/tab 1 tab ODHS
Ivabradine 5mg/tab 1 tab BID
ASA 80mg/tab 1 tab OD
Clopidogrel 75mg/tab 1 tab OD
Symbicort 160mg 14.5mg / 9/25 MGH
9/24 Culture: Staph haemolyticus : FEW, sensitive to chloramphenicol, tetracycline, vancomycin, Intermediate to Gentamycin
9/22 Occult blood (-)
9/21 Na urine 150.30 K urine 29.51 urine osmolality 562.00
9/20 sputum GS (+) yeast like cells, (+) PMNs >25/hpf, squamous epithelial cells >25/hpf
CBC: Hgb 79, RBC 2.63 hct 0.23 plt 288 WBC 3.80 Neut 0.70, lymph 0.25, mono 0.04, eos 0.01
UA: clear, light yellow, pH 7.8 (-)albumin, (-) sugar, bacteria few
9/17 CBC: Hgb 83, RBC 2.77 hct 0.24 plt 220 WBC 3.40 Neut 0.71, lymph 0.29
Na 129.00 K 4.14 / KUBP ultrasound
Bone marrow aspiration as Out-Patient
TCB for ff-up on Oct 5 Tues 8-12 am at Med OPD
TCB for ff-up on Oct 5 Tues 2pm at BCI with Repeat CBC results
Pneumococcal vaccine prior to discharge / Main:
PULMO
CV
Referral:
ID
ONCO: MAIN
PATIENT / DIAGNOSIS / MEDICATIONS / LABORATORIES/ANCILLARIES / PENDING / REFERRAL207H - DISCHARGED
Guda, Romeo Fullares
65/M
DOA: 09/15/10
CC: generalized weakness
CIC: Christine
Alt: Angie/Irish
Hosp. No. 02-80-71
Adm. No. 10I 00405 / Pancreatic head malignancy stage IV with liver and pulmonary metastases, ASHD, ACVD, LVH, NIF Class IIB, Hypertension Stage II, controlled, Hyponatremia probably secondary to SIADH secondary to pancreatic head malignancy, resolving, DM type 2, controlled / Metoprolol 100mg/tab 1 tab BID
Simvastatin 20 mg/tab 1 tab ODHS
Lactulose 30 cc ODHS
Amlodipine 10 mg/tab 1 tab OD
NaCl tab TID
Paracetamol 500 mg/tab 1 tab q6 for T>/=38.5C
Losartan 50 mg/tab 1 tab OD
Mixtard 12 u/SC at breakfast, 8 u/SC at dinner / 9/25 Chest CT scan: pulmonary nodule as described probably metastatic in nature. Slightly enlarged right lower paratracheal lymph node, minimal pleural effusion, right and lateral basal segment of the right lower lobe with subpleural bleb, left apex
Abdominal CT scan: heterogeneously enhancing hypodense mass region of the head extending to the body of the pancreas consider a pancreatic new growth. Multiple enhancing hypodense hepatic nodules likely metastatic. Left renal cortical cyst minimal ascites. Atheromatus abdominal aorta.
9/25 blood culture right foot and left arm: no growth after 5 days
9/25 TP 6.31, alb 2.14, glob 4.20, a/g ratio 0.50, hgb 113, hct 0.32, plt 407, wbc 27.80, neutron 0.82, bands 0.01, seg 0.81 lym 0.12, mono 0.02, eosi 0.04
9/24 CA19-9 33,256U/ml, crea 0.48, Na 133, K 3.78
9/21 Initial read MRI: multiple hyperintense areas at the (L) posterior frontal, (L) parietal, and (L) occipital areas; t/c Brain Metastasis or cerebral infarcts
9/20- Soduim 134.00 Potassium 3.85
9/20- CXR: Follow up study when compared to the one done on 9/15/10 no longer shows the previously noted nodular density at the left perihilar region. There is a nasogastric tube in place. The rest of the previously noted chest findings remains unchanged. If clinically warranted, a chest CT scan is suggested.
9/19- Fecalysis Brown, water with mucus + veg cell + starch granules, few yeast cells. 0-2/hpf pus cells, (++) mucus, few blastocystis hominis. Urinalysis: dark yellow, slightly turbid, pH 5.0 SG 1.020, (+) Albumin, ++ siugar, hyaline 01/coverslip, granular 02/coverslip, RBC 1-3/hpf, pus cells 1-3/hpf (+) bacteria ,+++ mucus threads
9/18 CBC hgb 120 rbc 3.80 hct 0.33 mcv 87.70 mch 31.50 mchc35.90 rdw 14.90 plt 358 wbc 31.20 neutro 0.79 lympho 0.14 eosino 0.02
9/18 Na 130.00 K 3.55
9/17 CA 19-9 > 10,000 U/mL
9/17 (4:15PM) Sodium 128 Potassium 3.88
9/17 (7:00AM) Sodium 129 Potassium 3.76
09/16 SGOT-AST 58.07 U/L HIGH, SGPT-ALT 48.42 U/L HIGH, Sodium 121.47 mmol/l LOW, K 3.89mmol/l
09/16 Alkaline phosphatase 479.33 U/L HIGH, Total Bilirubin 2.38 mg/dl HIGH, Direct Bilirubin 1.63 mg/dl HIGH, Indirect biirubin 0.75 mg/dl, Ionized calcium 1.15 mmol/l
09/16 Sodium 126.31 mmol/l LOW, K 4.06 mmol/l
09/16 Creatinine 0.53 mg/dl Sodium 124.00 mmol/l LOW, K 3.99 mmol/l
09/15 Na 126, K 4.39
09/15 plasma osmolality 282
09/15 Na 122, K 4.50
09/15 Na-urine 86, K-urine 75.05, urine osmolality 575
09/15 U/A dark yello, slightly turbid, pH 9, ap gr 1.015, albumin +, sugar ++, granular 02/coverslip, pus cell 1-3/hpf, bacteria ++, mucus threads few, amorphous phosphate ++
09/15 Hgb 124, RBC 3.98, HCT 0.37, plt 306, wbc 26, neutrophils 0.80, lymphocytes 0.17, monocytes 0.01, eosinophils 0.02
09/15 UTZ of LGBPS- normal sizedliver with diffuse parenchymal changes and multiple hepatic masses andnodules. Consider metastati process. Hypoechoic mass at the body of the pancreas. Primary newgrowth is considered. Thickened gall bladder wall. Cannot rule out thepossibility of cholecystitis. Spleen-normal. Multiple Peripancreatic and periportal lymph nodes, as described. Suggest CT scan correlation for further evaluation.
09/13 12 L ECG- Sinus rhythm, non-specific ST-T wave changes / Official result of chest and abdominal CT scan / Co manage: nephrology, endocrinology,
CV
Referral:
neurology
205 – E Discharged
Dizon, Alfredo C.
06-39-61
10I00662
DOA: 9/27/10
DOD: 9/29/10
CIC: GV Liabres
Alt: Jae, Joyce
Cc: for 3rd cycle of chemorx / Squamous cell carcinoma at the epiglottic larynx stage IVc (T4N2M1) s/p 3 cycles chemotherapy (Cisplatin + 5 FU) s/p 2 cycles of concurrent chemoradiotherapy (Cisplatin) / Cisplatin 100mg/m2
KCl
Mannitol 20%
MgSO4
Ondansetron 8mg/IV
Dexamethasone 200mg/IV
Metoclopramide 10mg/sup / 9/28/10: Serum creatinine 1.07mg/dl
9/26/10: Serum creatinine (done outside UST) 1.18 mg/dl
9/26/10: CBC with plt (done outside UST) – hgb 89, hct 0.28, RBC 2.8, WBC 3.4, plt 373, MCV 100, MCH 32, MCHC 322, segmenters 0.57, lymphocyte 0.33, monocyte 0.08, eosinophil 0.02
9/20/10: Serum creatinine 1.4 mg/dl, ALT/SGPT 11 IU/L
205 – F
Cabiasa, Rochel C.
06-19-10
10I00711
DOA: 9/29/10
CIC: Jae
Alt: GV, Joyce
Cc: hemoptysis / NPCA st.3 (T3N2M0) s/p 3 cycles adjuvant chemotherapy, s/p 3 cycles concurrent chemotherapy r/o tumoral bleeding / Tranexamic 500mg/cap
Co-Amoxyclav 1g/tab
Clindamycin 300mg/tab / 9/29: CBC with plt – hgb 73, rbc 2.61, hct 0.22, MCV 82.5, MCH 27.9, MCHC 33.8, RDW 14.7, MPV 5.3, plt 599, WBC 16.1, neutrophils 0.96, segmented 0.96, lymphocytes 0.04
9/29: Coagulation assay – PT 13.8 secs, N control 12.0s, PT ratio 1.1, INR 1.1, aPTT 34.4s, N control 34.3
9/29: CXR official result – slight resolution of previously noted (R) lung infiltrates, residual ill-defined infiltrates on (R) infraclavicular region which may relate to minimal tuberculous lesions, heart not enlarged, tracheostomy tube seen, NGT seen with its tip on upper outer quadrant of the abdomen, osseus structures unremarkable / Tracheal aspirate C & S / Referral: ENT
RHEUMA: MAIN
PATIENT / DIAGNOSIS / MEDICATIONS / LABORATORIES/ANCILLARIES / PENDING / REFERRAL207E
Tariga, Jose N.
57/M
DOA: 9/29/10
CC: bilateral knee joint pains
CIC: Christine
Alternate: Angie/Irish
Hosp. No.: 00-44-87
Adm. No.: 10I00708 / Acute gouty arthritis in flare
t/c septic arthritis
ASHD, CAD, HCVD, LVH, out of failure, Class III-C
Atrial fibrillation probably secondary to dilated cardiomyopathy / Dolcet tab 1 tab q8 prn for pain
Colchicine 0.5mg/tab BID
Digoxin 0.25mg/tab 1 tab q48
Coumadin 2.5mg/tab 1 tab OD
Metoprolol 50mg/tab 1 tab BID
Amlodipine 5mg/tab 1 tab OD / 9/29 Synovial fluid: GS – no microorganisms seen, total RBC 2,800/cu mm, total WBC 14,600/cu mm, neu 92%, lym 8%
9/29 PT 27.3, aPTT 66.0
9/29 CBC hgb 158, hct 0.26, plt 239, wbc 11.60, neu 0.82, lym 0.18; BUN 25.81, crea 1.25, SGOT/AST 27.10, SGPT/ALT 26.85, Na 129.58, K 4.44
9/29 CXR initial read: Lung fields clear, cardiomegaly, atheromatous aorta, bibasal hyperaeration / CV (Co-manage)
RHEUMA: REFERRAL
PATIENT / DIAGNOSIS / MEDICATIONS / LABORATORIES/ANCILLARIES / PENDING / REFERRAL302 F
DELA CRUZ, Rodolfo R.
62/M
DOA: 09/25/10
CC: fever
CIC: Bianca Gaffud
Alt: Tal/ Steph
Hosp #: 07-22-61
ADm #: 10I00617 / Obstructive uropathy 2ndary to ureterolithiasis proximal 3rd L, nephrolithiasis L, s/p pyelolithotomy L; acute gouty arthritis / Allopurinol 10mg/tab OD
Losartan 50mg/tab OD
Simvastatin 40mg/tab OD
Felodipine 2.5mg/tab OD
Colchicines 0.3mg/tab OD
K citrate + NaHCO3 (Ural) TID
Senohot tab 2 tablets ODHS
Dolcet tab 1 tab TID prn for pain
Co-amoxiclav 625mg/tab 1 tab BID for 7 days
Diet: low purine diet / 9/29/10 CBC: Hb: 102; RBC: 3.23; Hct: 0.30; MCV: 92.00; MCH: 31.50; MCHC: 34.20; RDW: 13.10; MPV: 6.30; plt: 298; WBC: 12.30; neut: 0.78; segm: 0.78; lymph: 0.20; mono: 0.01; eos: 0.01
9/28/10: urine culture: Enterococcuc faecalis 7,000 CFU/ml; sensitive to: ampicillin,norfloxacin,iprofloxacin,penicillin,nitrofurantoin, vancomycin; resistant to: tetracycline
9/25/10: U/A: yellow, turbid, pH 5.0, sp. Gr. 1.020, albumin ++, sugar negative, RBC: 1-2/hpf, pus cell: over 100/hpf, bacteria ++++
9/25/10: LOW Hb: 110; LOW RBC: 3.49; LOW Hct: 0.32; MCV: 92.80; MCH:31.50; MCHC: 34.00; RDW: 13.60; MPV: 6.20; plt: 355; WBC: 29; neut: 0.90; segm: 0.90; lymph: 0.10
9/25/10: Uric acid: 8.33; HIGH creatinine: 1.85; LOW Na: 131; potassium:4.45 / Main: urology
316 I
Caracas, Allaysa Marie D.
12/F
DOA: 09/23/10
CC: difficulty of swallowing
CIC: Angie
Alt: Christine/Irish
Hosp No. 05-10-28
Admission No. 10I0059 / Juvenile Dermatomysistis, Oropharyngeal Candidiasis, t/c Candidal Esophagitis, Pneumonia / Hydroxychloroquine 200 mg/tab 1 tab OD
Prednisone 5 mg/tab 1 tab OD after breakfast
Azithromycin 200 mg/5 mL, 2.5 mL on day 2-5
Paracetamol 250 mg/5 mL, 5 mL for T>/=38.5C
Cefuroxime 500 mg/SIVP q8
Multivitamins syrup 5 mL OD / 9/26 Na 137.4, K 4.63
9/24 CBC: Hgb 101 RBC 2.97 Hct 0.27 MCV 90.10 MCH 33.90 MCHC 37.70 RDW 13.10 Plt 398 MPV 7.0 WBC 8.80 Neu 0.79 Seg 0.79 Lym 0.19, Eo 0.02
9/24 CXR: Initial read – interstitial confluent densities right pericardiac area with prominent hilar lymphadenopathies / For EGD / Main: Pediatrics
318 G
Urian, Juan Miguel Berbosa
4/M
DOA: September 25, 2010
CC: abdominal pain
CIC: Joyce
Alt: GV/Jae / Henoch-Schonlein purpura / Methylprednisolone 15mg/SIVP q8h / 9/25: CBC c plt – hgb 159, RBC 5.31, hct 0.46, MCV 85.70, MCH 30, MCHC 35, RDW 13.4, MPV 13.4, MPV 5.70, ptl 527, WBC 16.80, Neutrophils 0.75, Seg 0.75, Lymphocytes 0.25, ESR – mod Nestergren 12.0
9/25: High-sensitive CRP – 10.40 mg/L (high)
9/25: Urinalysis – yellow, sl. Turbid, pH 6.5, Sp. Gravity 1.020, Albumin/sugar (-), RBCs 0-1/hpf, Bacteria +, Mucus few, / Awaiting for official SFA result / Main:
Pedia
Referral:
rheuma