ROOM #: 605 SERVICES: Surgery, Pedia

NAME: GUETIEREZ JAZZIE AGE: 3 SEX: FEMALE MD: Dr. Saguil/ Gaddi/Santos/ Halili/ Ebron/ Valena/ Conde
DIAGNOSIS: ACUTE APPENDICITIS, Presumptive UTI DIET: NPO
VITAL SIGN I and O: Q4
FREQUENCY: Q4
PROCEDURE: For emergency open appendectomy MEDICATIONS DIAGNOSTICS

HISTORY D5LR 1L X 54CC/HR 6/28/23 Abdominal Ileus

9 days PTC, abdominal pain hypogastric area with nausea, vomiting, fever. 8 days PTC Ceftriaxone 1.7 g TIV Xray
consulted private MD of presumptive UTI given co-amoxiclav 50mg/kg/day q12 and then 800 mg TIV Q12 6/29/23 KUB UTZ Enlarged kidnety bilateral with signs
paracetamol 10mg/kg/dose, no relief of symptoms. 7 days PTC, still hypogastric pain, consult Omeprazole 17 mg of renal parenchymal disease
Tondo General Hospital. CBC and UA done. Medication given unrecalled. 5 days PTC. TIV OD
Hypogastric pain, epigastric tenderness, nausea, fair appetite. 1 day PTC, persistence Paracetamol 250 mg 7/2/23 CT Abdomen findings of acute AP, small bowel
abdominal pain at hypogastric area. CT scan done showed Appendiceal pathology. Transfer to TIV q6 PRN thickening, reactive inflammatory
institution enteritis. Mesenteric
ROS: (-) cough, golds, dysuria, loose stools, weakness, w/ good appetite lymphadenopathy
PMHx: AGE (20222) (-) surgery and allergies, complete immunization
FMHX: hypertension (paternal)
PSHx: 2nd of 2 child. Mother 35 y/o college assistant. Father 33y/o

PE: Distended nontender abdomen, CRT <2sec, direct tenderness on abdomen, no guarding
Ht:104 cm. Wt. 17.2 kg

COURSE IN THE WARD LABORATORIES

7/2/23 Elecs Low Na 134.9, N Potassium 4.7, N Chloride 101.0
7/2/23 Elecs Hight WBC 19.6, RBC 5.1, Hgb 13.1, HCT 38.9, Low MCV 76.3, Low MCH
7/3 Admitting: CBC, PT. PTTT. BUN Crea, Na, K, Cl, UA, Ceftriaxone, Omeprazole, 25.8, Low MCHC 25.8, Hight RDW 14.3, MPV 9.3, Hight Neutro 60.7,
Paracetamol PRN. For emergency open appendectomy Low Lympho 27.8, High Mono 9.3, Eosino 1.7, High Baso 0.5, High PLT
GS: for pedia risk stratification, book to OR and anes 729.
Pedia: Suggested IVF D5 LR 1360 cc/hr. Elecs, CXR, Urine CS/GS, Ceftri, Para. Refer 7/3/23 UA yellow, turbid, ketone +2, protein trace, EC occasional, MT few, AP few,
to Pedia ward drop IDRF. Refer back if with dx results WBC 3-5, RBC 2-4

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ROOM #: 702 SERVICES: Surgery
NAME: GAIN KENNETH AGE: 23 SEX: MALE MD: Dr. Agida??/ Gaddi/Santos/ Halili/ Ebron/ Valena/ Conde
DIAGNOSIS: T/C ACUTE APPENDICITIS, EQUIVOCAL DIET: DAT, NPO if with abdominal pain
VITAL SIGN I and O: shift
FREQUENCY: Q8
PROCEDURE: MEDICATIONS DIAGNOSTICS

HISTORY PNSS 1L x 80 cc/hr WAB CT with

3 days PTA, RLC abdominal pain aggravated with urination with undocumented fever. No Cetriaxone 2g TIV Contrast
consult done. .Interim, on and off abdominal pain (-) nausea and vomiting, anorexia. Day of then 1g Q12 – d/c
admission RLQ pain persisted. consult Tramadol 50 mg TIV
PRN – d/c
ROS: Omeprazole 40 mg
PMHx: no comorbidities TIV OD
FMHX: Paracetamol 600 mg
PSHx: TIV q6 PRN
Ketorolac 30 mg TIV
PE: anicteric sclera, pin palpebral conjunctiva, equal chest expansion, clear breath sounds, soft PRN
direct tenderness RLQ, non-distended
Ht:104 cm. Wt. 17.2 kg

COURSE IN THE WARD LABORATORIES

7/3/23 Clin Na 139.4, Potassium 3.66, Chloride 102. BUN 4.4, Crea 80.80
Chem
7/3 Admitting: CBC, PT. PTTT. BUN Crea, Na, K, Cl, UA, WAB CT with IV contrast. 7/3/23 Coag PT control 12.1, PT 13, INR 1.05, %Activity 93.4, APTT 33.80
Ceftriaxone, Omeprazole, Paracetamol PRN. For serial abdominal examination 7/2/23 WBC 8.4, RBC 5.4, Hgb 15.8, HCT 46.8, MCV 87, MCH 29.5, MCHC 33.8,
RDW 12.3, MPV 8.1, Neutro 60, Lympho 30.8, Mono 6.7, Eosino 1.3,
7/4 GS: Same as above. D/C ceftriaxone. Tramadol Baso 0.5, PLT 269.
7/5 GS: ff up WAB CT with contrast result. Ketrorolac PRN, D/C Tramadol. 7/2/23 UA yellow, slightly turbid EC few, MT moderate, AU few, WBC 1-2, RBC 0-1
For discharge tomorrow Bacteria Few

PENDING ORDERS
 ROOM #: 701 SERVICES: Surgery
NAME: CARALE, ABRAHAM AGE: 51 SEX: MALE MD: Dr. Villanueva/Villero/Santos/ Mascarinas/ Alipon/Valena
DIAGNOSIS: Rectosigmoid adenocarcinoma DIET:Dash diet at 1900 kcal
St 2 A (T3 NO MO) or Stage 4 (T3 NO M1)**** VITAL SIGN I and O: shift
FREQUENCY: 4 CBG Q6
PROCEDURE: for elective anterior resection with end to end anastomosis (Handsewn) MEDICATIONS DIAGNOSTICS

HISTORY PLR 1L c 12 cc/hr – shifted Chest CT with

to HL
7 months PTA, epigastric pain with blood in stool, consulted to IM was given antacid and pain contrast
medication. Interim recurrence of symptoms. Underwent CT scan 2 cm mass on the sigmoid. Ceftriaxone 1 g IV q12 ECG
Colonoscopy was done and rectal mass was biopsied. Referred to surgery. Few hrs PTC Metronidazole 500 mg IV
experience hypogastric pain radiating to back. Consulted to the institution q8
Omeprazole 40 mg IV OD
MRI with staging
Paracetamol 600 mg IV protocol
ROS:
PRN WAB CT with
PMHx: HTN Ketorolac 30 mg IV PRN
FMHX: D 50-50 vial PRN
contrast
PSHx: Tramadol 50 mg IV PRN
Multivitamin OD
PE: direct RLQ tenderness
Ht:104 cm. Wt. 17.2 kg

COURSE IN THE WARD LABORATORIES

7/3/23 Clin BUN , Crea, AST, ALT, Na, K, Cl
Chem
7/5 NPO. PLR. CBC, PT PTT, BTRH, CEA, UA, BUN, Crea, Na, K, Cl, AST, ALT, CXR,ECG, CT 7/3/23 Coag PT control , PT, INR , %Activity , APTT
Scan tripe contrast 7/2/23 WBC , RBC , Hgb , HCT , MCV, MCH, MCHC, RDW, MPV, Neutro ,
Lympho , Mono , Eosino , Baso , PLT .
GS: Dash Diet. Heplock. For pelvic MRI with staging protocol. Chest CT with IV 7/2/23 UA yellow, slightly turbid EC few, MT moderate, AU few, WBC 1-2, RBC 0-1
contrast Bacteria Few

PENDING ORDERS

GUTIERREZ
GAIN
VERSOZA – no pics

CARALE
FERNANDEZ
FERRER

CAMERO
BATRINA
GREGORIO