Trauma Male A: General Surgery: Team I Dr. Tamani/Lingan/Aguisanda/Baculi/Casco/ Bulusan

GENERAL SURGERY: TEAM I
DR. TAMANI/LINGAN/AGUISANDA/BACULI/CASCO/ BULUSAN/ padilla/soriano/ravivarma/raveendran/nagui/shanmugam/navalta/felix
JANUARY 22, 2020
TRAUMA MALE A
PATIENT DIAGNOSIS MEDICATIONS DIAGNOSTICS
NITRAT
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD Leukocyte RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1Lx16hour E
TM-A INITIAL DX: DIET: DAT 1/102020
ANCILLARY:
MULTIPLE PHYSICAL
INJURY SECONDARY MEDICATION:
LEDESMA, EDGAR SERANO TO VEHICULAR 1. Losartan 50 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; MULTIPLE mg BID 1/06/20 15.3 151 0.43 75.2 16.9 7.2 0.4 0.3 267 102 36 350
53/M
RIB FRACTURE 3RD-5TH 2. Amplodipine
RIGHT CLAVICULAR 10 mg OD
FRACTURE RIGHT, 3. Ampi-sul 1.5
DOB:06/15/66 PULMONARY gm TIV q8
CONTUSION RIGHT 4. Salbutamol +
CHEMISTRY CREA BUN Alb Globu NA K CL FAS GLU CHOOL TRIGL HDL LDL ALT AST TB TP A/ CEA B1/B2
DOA: 01/06/20 Ipratropium lin E Y G
neb q6 1/11/20 28 27.80 60 94 221. 55 1.0 86.8/3
3 6.2
5. Nicardipine
drip: 90cc 1/09/20 6.10 3.43 0.77 0.94 2.14
CC: VEHICULAR ACCIDENT pNSS + 1amp 1/06/20 142. 4.06
Nicardipine to 1
run for 15 PT INR % Control PTT Control

HISTORY: gtts/min
NOI: VA 1/11/20 13.20 1.06 90.4 34.3
MONITOR VS q4 and
TOI: 6:30AM record
Monitor input and
POI: PENABLANCA, CAGAYAN output q shift
DOI: 01/06/20 PLAN:

Possible MGH
17th hospital day Pull out CTT
Novi
TM-A
IVF: PNSS 1LX 8 HRS UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
Leukocyte RBC WBC EPITH HYALI BACTERIA
GUZMAN, JAY R DALUDADO INITIAL DX: DIET: DAT WITH SAP E
34/M MULTIPLE PHYSICAL MEDICATION:

INJURY SEC. TO VA, CELECOXIB 200MG/CAP
DOB: 01/21/20 MULTIPLE RIB BID FOR PAIN
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
FRACTURE 8TH TO SALBUTAMOL +
DOA: 1/21/20
9TH RIBS, RIGHT IPRATOPRIUM NEB 1/21/20 25.4 0.41 144 87.2 5.9 6.5 0 0.4 388 82 29 356
CC: VA TRAMADOL 50MG/ IV

Q8 FOR PAIN
NOI: VA CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA
ALBU GLOBU
AST ALT TB TP A/G CEA
PLAN: MIN LIN
TOI: 7:30 PM MGH 1/21/20 137.60 3.36
POI: AMULUNG
CONTR
PT % INR APTT
OL
DOI: 1/20/20
1/21/20 13.40 95.20 1.04 30.10
2nd Hospital stay
NITRAT
IVF: PNSS 1L x KVO E
TM-A INITIAL DX: DIET: Diet for age
MULTIPLE PHYSICAL
ANCILLARY: CTT output
INJURY SECONDARY
CATAGGATAN, MIYA CALATA 400cc
TO VEHICULAR
ACCIDENT CEREBRAL MEDICATION:
33/M
CONCUSSION LINEAR 1. Ampicillin-
1/20/20 20.1 94 0.27 80 16 3.5 0 0.2 510
DOB: 10/24/2019 SKULL FRACTURE Sulbactam 162.5g

FRONTAL RIGHT IV q6
DOA: 01/20/2020 2. Paracetamol
90mg/IV
CC: VEHICULAR ACCIDENT 3. Ranitidine CHEMISTRY CREA BUN AMY LIP NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
ASE
6.5mg/IV 1/20/20 135.50 4.41
4. Ampicillin
HISTORY: Sulbactam
170mg/IV PT % INR CONTROL APTT CONTROL
NOI: VA
MONITOR VS q4 and
record
TOI: 8PM
POI: CABAGAN ISABELA PLAN:

MGH
DOI: 01/20/2020
3rd Hospital day
TM A INITIAL DIAGNOSIS IVF: D5LRS 1L X 8 HRS NITRAT

DIET: SOFT DIET WITH E
SORBANO JOHNNY URANI EPIDURAL SAP
42/M HEMATOMA RIGHT,
FRONTOTEMPOROPA MEDICATION: Mannitol CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 4-7-1977 RIETAL 150cc/IV 1/18/20 20.8 138 0.40 89.7 3.6 6.6 0.0 0.1 287 92 32 342
INTRACEREBRAL Ceftriaxone 2g/IV
DOA:1/15/20
HEMATOMA RIGHT Omeprazole 40mg/IV
CC: Vehicular Accident FRONTAL Ketorolac 30mg/IV
SECONDARY TO Ascorbic acid 500mg/
NOI:VA VEHICULAR tab
ACCIDENT B complex tab
TOI:3PM
PLAN:
DOI:1/15/20 Facilitate CT scan
POI: TUMAUINI
8th HOSPITAL STAY
Trauma Male B
NITRAT
IVF: PNSS 1L X 8hr E
TM-B INITIAL DX: DIET: DAT with SAP 1/10/2020 LY Clear 1.015 7.5 - - ++ - - - - - 86 2 1 0 7
ACUTE EPIDURAL ANCILLARY:

HEMATOMA, RIGHT MEDICATION: Ampicillin-
LAURETA, REYNARD CALMA FRONTOTEMPOROPA Sulbactam 1.5g/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
RIETAL LEFT; Omeprazole 40mg/IV 1/14/ 20 10.9 107 0.31 82 9.7 5.8 2.2 0.3 231 93 33 351
FRONTOTEMPOROPA Tranexamic Acid
RIETAL; SKULL 500mg/IV
FRACTURE LEFT Ketorolac 30mg/IV
DOB:Oct 18 1999 FRONTAL;
NEUROCEPHALOUS
CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOA: 01/10/20 MONITOR VS q4 and
record 1/14/20 135.1 2.97
CC: VA Monitor input and
1/13/20 138.30 3.57
output q shift
23rd HOSPITAL DAY
PLAN: PT INR % Control PTT Control
MGH
Bincey 1/13//20 13.30 30.30
NITRAT
IVF: PNSS 1L X 12hr E
TM-B INITIAL DX: DIET: DAT with SAP 1/16/2020
DARK
Clear 1.020 7.5 - Trace Trace - - + - - 33 258 2 0 31
YELLOW
INTRAPARENCHYMAL ANCILLARY:
BLEED PROBABLY MEDICATION:
ATTABAN, EDRIEL APOSTOL SECONDARY TO toclopramid 10mg/IV
ARTERIOVENOUS Ceftriaxone 1g/IV
17/M 1/19/ 20 9.3 119 0.37 50 25 8.7 14.4 1.0 327 62 20 320
MALFORMATION Paracetamol 300mg/IV 1/21/20 12.4 125 0.40 52.8 21.4 6.9 18.3 0.6 447 63 20 313
Mannitol 120cc/IV q4
DOB:Feb 28-2002
MONITOR VS q4 and
DOA: 01/10/20 record
Monitor input and CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
CC: output q shift 1/16 72 131 3.78
13th HOSPITAL DAY PLAN: 1/21/20 137.80 4.33
Refer Back prior to

discharge PT INR % Control PTT Control
MGH
1/19//20 13
TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT

DIET: DAT with SAP E
MASCARINAS, CLARENCE JESSIE ACUTE EPIDURAL 1/18 LY CLEAR 1.030 6.5 - - ++ - - + - - 8-10 2-3 - - +
CORTEZ HEMATOMA, ANCILLARY:

FRONTOTEMPOROPA
6/M RIETAL RIGHT MEDICATION:
SECONDARY TO FALL Ampicillin-Sulbactam CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 05/8/2013 1.5g TIV q8 1/18 7.6 103 0.30 62 31 5.4 0.4 0.7 344 80 28 344
Ketorolac 30 mg IV q8
DOA: 01/18/20
PRN for pain
CC: FALL Omeprazole 40 mg TIV
q24
NOI: FALL CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
Monitor VS q2 and ISTRY SE MIN LIN G
TOI: 10PM record 1/18 140 4.26
Monitor I & O qshift and /20
POI: ILAGAN ISABELA record PT INR % Control PTT Control
PLAN:
DOI: 1/18/20 Repeat Cranial CT scan
1/18/2020 14.50 39.80
5th HOSPITAL DAY
TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT

LAWAGAN, BRYAN GARRO MULTIPLE PHYSICAL 1/18 LY CLEAR 1.030 6.5 - - ++ - - + - - 8-10 2-3 - - +
INJURY SECONDARY ANCILLARY:

20/M TO VA, MINIMAL
ACUTE SUBDURAL MEDICATION:
DOB: 05/11/1999 Ceftriaxone 1gm/IV
HEMATOMA RIGHT CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
PARIETAL LINEAR Omeprazole 40mg/IV
DOA: 01/18/20 1/18 10 102 0.31 72 19 7 0.1 0.3 301 90 30 330
SKULL FRACTURE, Ascorbic acid 40mg/IV 1/20 8.6 100 0.29 69.3 22.2 8.1 0.2 0.2 295 89 30 341
CC: VEHICULAR ACCIDENT RIGHT PARIETAL, Mannitol 100cc/IV

PNEUMOCEPHALUS, Gentamycin 240mg/IV
NOI: VA OPEN FRACTURE LEG Pen G 5 milli units
LEFT CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
TOI: 8AM Monitor VS q2 and ISTRY SE MIN LIN G
record 1/18 139 4.49
POI: TUMAUINI ISABELA Monitor I & O qshift and /20
1/20 139.40 4.49
record
PLAN:
DOI: 1/18/20 Maintain mannitol 75cc
PT INR % Control PTT Control
q6 with BP precaution
th
5 HOSPITAL DAY WOF neurodegeneration
1/18/2020 14 27
TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

DIET: NPO E
MEDALLA. ERICKSON ACUTE SUBDURAL MEDICATION:
HEMATOMA, LEFT Ampicilin-Sulabctam
18/M PARIETAL AREA 1.5g IV q8
SECONDARY TO Omeprazole 40mg/IV
DOB: 11/18-2001 Mannitol/100cc/IV
VEHICULAR CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT ketorolac 30mg/IVq8 1/21 26 158 0.47 89 4.5 6.6 0 0 390 90 30 338
DOA: 01/20/20
CC: VEHICULAR ACCIDENT PLAN:

Continue Present
NOI: VEHICULAR ACCIDENT Medications CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
Daily wound care

TOI: 9PM 1/21 139.10 4.08
WOF neurodegeneration
hook to 02 support at 2-
DOI: 1/20/20 3LPM via NC
3rdHospital stay
1/21 14.30 32.20

SARDON, NESTOR CAMAGON MULTIPE PHYSICAL
46/M TO VEHICULAR Mannitol 150cc/IV
ACCIDENT, Diphenhydramine
DOB: 8/16/73
CONTUSION 50mg/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOA: 01/16/20 HEMATOMA RIGHT KCL drip: 90ccPNSS 1/19/20 9.5 94 0.27 87 6.6 5.1 0.1 0.3 222 90 32 352
TEMPOROPARIETAL +10meqs KCL

CC: VEHICULAR ACCIDENT ACUTE EPIDURAL
HEMATOMA LEFT PLAN:
NOI: VEHICULAR ACCIDENT PARIETO-OCCIPITAL Continue Present CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
TRAUMATIC Medications
TOI: 10PM 1/20/20 3.52
SUBARACHNOID
1/19/20 136.40 2.88
HEMORRHAGE
DOI: 1/16/20
POI: STA TERESITA
7TH Hospital stay

DIET: Low fat low salt E
diet 1/20/20 YELLOW HAZY 1.020 6.5 - ++ + - - + - - 5-8 3-5 FEW
DOMINGO NORMAN MULTIPLE PHYSICAL
19/M TO VA, ACUTE Ampicilin-Sulabctam
SUBDURAL 1.5g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 1/20/2000
HEMATOMA RIGHT Mannitol 150 cc IV q4 1/20 25 137 0.42 86 4.6 8.4 0 0.2 269
DOA: 01/20/20 FRONTOTEMPOROPA with BP precaution

RIETAL WITH Ketorolac 30 mg/IV q8
CC: VEHICULAR ACCIDENT INTRACEREBRAL PRN for pain
HEMATOMA Kcl drip: 900cc PNSS +
NOI: VA BIFRONTAL AREA, 10 meqs Kcl x 1 hr x 2 CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
SUBARACHNOID cycles
TOI: 12AM HEMMORHAGE 1/14/20 136.40 3.71
PLAN: 1/18/20 136 3.49

DOI: 1/20/20
MGH
3rd Hospital stay PT INR % Control PTT Control

DIET: Low fat low salt E
BALANAY, ERNESTO BIGGAYAN CONTUSION diet 1/102020
HEMATOMA, LEFT
68/M TEMPOROPARIETAL MEDICATION:
AREA Ampicilin-Sulabctam
DOB: 10/15/1951
1.5g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOA: 01/14/20 Mannitol 150 cc IV q4 1/14/20 25.1 128 0.38 88.2 3.7 8.7 0.1 0.2 230 90 31 338
1/18/20 10.8 131 0.38 68 14 5.8 10.7 0.7 351 89 31 346
with BP precaution 1/21/20 15.5 140 0.41 70.4 12.3 6.0 10.8 0.5 427 90 31 343
CC: LOC Ketorolac 30 mg/IV q8
PRN for pain
NOI: FALL Kcl drip: 900cc PNSS +
10 meqs Kcl x 1 hr x 2
TOI: 7 PM cycles CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
Salbutamol + Iprat neb

DOI: 1/06/20 q8
1/14/20 136.40 3.71
1/18/20 136 3.49

9th Hospital stay
PLAN: 1/21/20 134.40 3.38
Repeat CBC Na K
Repeat Cranial CT scan PT INR % Control PTT Control
TM-B INITIAL DX: IVF: D5LRS 1L X 12 HRS NITRAT

ESTABILLO, ARIEL CABANSAG MULTIPLE PHYSICAL
INJURY SECONDARY MEDICATION: Mannitol
19/M TO VEHICULAR 150cc/IV
ACCIDENT. MINIMAL Ceftriaxone 2g/IV
DOB: 01/16/2001
ACUTE SUBDURAL Omeprazole 40mg/IV 1/18/20 20.8 138 0.40 89.7 3.6 6.6 0.0 0.1 287 92 32 342
HEMATOMA, RIGHT Ketorolac 30mg/IV

DOA: 01/18/2020 FRONTAL SKULL Ascorbic acid 500mg/
FRACTURE FRONTAL tab
CC: INGESTION OF ZONROX AREA B complex tab
CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
5th Hospital stay ISTRY SE MIN LIN G
PLAN: 1/18 135 3.85
Continue Medications /20
1/21 4.32
WOF nuerodegeneration
1/18/20 15.50 40.10
AISLES RIGHT
CRITICAL CARE ROOM
NITRAT
IVF: E
CCR INITIAL DX: DIET:
MULTIPLE PHYSICAL ANCILLARY:

INJURY SECONDARY
AGRIAM, MARY ROSE SOSA TO VEHICULAR MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT,
42/F 1/18/20 19.6 120 0.34 91.8 3.8 4.3 0 0.1 161
TRAUMATIC
DOB:12/18/1977 SUBARACHNOID
HEMORRHAGE CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOA: Jan 18 2020 SECONDARY TO PLAN:

59 145 3.88
VEHICULAR
CC: Vehicular Accident ACCIDENT PT % INR CONTROL APTT CONTROL
1/18/2020 18.70 35.60
NOI: Vehicular accident
TOI: 3pm
DOI: 1/18/20
POI: CLAVERIA, CAGAYAN
EXPIRED
IVF: NITRAT
CCR INITIAL DX: DIET:
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
E
Leukocyte RBC WBC EPITH HYALI BACTERIA
ANCILLARY:
JARA, JUDY JR SEATRIZ T/C BRAIN ABSCESS,
RIGHT MEDICATION
34/M CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
FRONTOTEMPORAL
1/14/20 9.7 159 0.46 71.9 19.6 7.2 1.1 0.2 322 85 30 348
DOB: 04/29/1985 PLAN:
S/P E' CRANIECTOMY,
DOA: 01/14/20 RIGHT EVACUATION
OF HEMATOMA FOR
CC: GENERALIZD BODY WEAKNESS ACUTE EPIDURAL
HEMATOMA,
CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
TEMPORO-PARIETAL,
(+) HEADACHE RIGHT WITH 1/15/20 75.20 136.8 4.08 93
.6
DEPRESSED SKULL
(+) DIZZINESS
FRACTURE , RIGHT
PT % INR CONTROL APTT CONTROL
(+) N/V FRONTOTEMPOROPA
1/14/20 14.80 1.17 75.80 25.80
RIETAL SEC. TO VA
ESR: 24mm/hr
EXPIRED
AISLES LEFT
TRAUMA FEMALE A
PATIENT DIAGNOSIS MEDICATIONS DIAGNOSTICS
NITRAT
IVF: PNSS 1 L X 12 HRS E
TF-A INITIAL DX: DIET: DAT with SAP
CAPINLAC, ROMAN BASA CONTUSION
ANCILLARY: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
HEMATOMA, RIGHT
58/M
FRONTOTEMPORAL 1/15/20 10.8 169 0.46 73 17 8.8 0.1 0.8 212 81 30 365
MEDICATION
DOB: 11/20/1963 AREA SEC. TO FALL
Ampicillin- Sulbactam
1.5 g IV q8
DOA: 01/15/2020
Mannitol 150 cc q4
Ketorolac 30 mg q8 IV
CC: LOC CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
PRN for pain
1/15 133 3.24
NOI: FALL
PLAN: 1/16 13.30 5.04 1.37 1.29 3.12
TOI: 5PM MGH PT % INR CONTROL APTT CONTROL
1/15/20 13.50 27.10

DOI: 1/12/20
POI: ISABELA
8th HOSPITAL DAY
NITRAT
IVF: PNSS 1L x 16hrs E
TF-A INITIAL DX: DIET: DM DIET 1/10/2020
MULTIPLE STAB ANCILLARY:

WOUND 8TH
ARNEDO, SEVERINO GALARCE INTERCOSTALS MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
SPACE, RIGHT. LEFT Human Albumin, 1 Vial 1/09/20 11.3 96 0.28 88 6.8 4.3 0.6 0.3 345 83 29 347
57/M
UPPER QUADRANT. to run for 6hours q12
POSTERIOR ARM,
LEFT MONITOR VS q2 and CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
record 1/09/20 3.63 142.61 98.64

DOB:07/26/1967 Monitor input and
1/12/2020 4.11
output qshift
DOA: 1/14/2020 21 26.30 47 0.8
0
PLAN: PT % INR CONTROL APTT CONTROL
CC: Stab wound Wound Flushing q12
Encourage ambulation
Give paracetamol 1g/IV
Jesserene
Apply ice pack to Left
arm
TRAUMA FEMALE B
IVF: PNSS 1L 8hours UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRITE Leukocyte RBC WBC EPITH HYALI BACTERIA
TF-B INITIAL DX: DIET: DAT with SAP DY Hazy 1.010 7.5 - TRACE + - - - - 24 5 1 1
-
PNEUMOHEMOTHOR ANCILLARY:
AX SECONDARY TO CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
LIZARDO, EDUARDO JR. UBERITA STABWOUND MEDICATION: 1/07/20 14.3 115 0.35 64.5 14.7 10.0 10.4 0.4 360 90 30 329
1/9/2020 16.2 131 0.40 70 13.7 13.3 2.6 0.4 256 88 29 328
ANTERIOR CHEST 6TH 1. Celecoxib
22/M 1/15/20 17.6 132 0.39 65.4 19.2 7.2 7.5 0.7 474 86 29 336
INTERCOSTAL SPACE 200mg/cap, 1
MIDCLAVICULAR LINE cap BID PRN
LEFT for pain
DOB:09/08/97 2. Salbutamol
neb q6
DOA: 01/09/20 3. Ampicillin-
Sulbactam CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
1.5g IV q8
1/07/20 134.30 4.16
CC: STAB WOUND 1/15/20 136.10 4.15
PLAN: PT % INR CONTROL APTT CONTROL
MGH
HISTORY:
NOI: STAB WOUND
TOI: 11PM
POI: LASAM, CAGAYAN
DOI: 11/07/20
13th HOSPITAL DAY
POST OP DAY 11
bincey
IVF: PNSS 1L 12hours UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRITE Leukocyte RBC WBC EPITH HYALI BACTERIA
TF-B INITIAL DX:

MULTIPLE PHYSICAL DIET: DAT with SAP DY Hazy 1.010 7.5 - TRACE - + - - - - 24 5 1 1
INJURY SECONDARY
CORPUZ, JERICO MACAPAGAL TO VEHICULAR ANCILLARY:
ACCIDENT, ACUTE CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
16/M MEDICATION:
EPIDURAL 1/20/20 10 121 0.36 64 26 6.7 2.3 0.5 553 84 28 334
HEMATOMA 4. Ceftriaxone
PARIETOOCCIPITAL 1g/IV
AREA RIGHT; 5. Ketorolac
DOB:09/17/2003
PNEUMOCEPHALUS 3mg/IV
CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
DOA: 01/20/20 6. Mannitol
LINEAR SKULL
100cc/IV q8
FRACTURE 1/20/20 136.70 3.68
7. Paracetamol
1g/IV
CC: Vehicular accident 8. Tranexamic
Acid1g/IV
HISTORY:
PLAN:
NOI: VA Refer to OPTHA and ENT
TOI: 12am
POI: Mallig Isabela
DOI: 11/20//20
3RD HOSPITAL DAY
NITRAT
IVF: PNSS 1Lx KVO E
TF-B INITIAL DX: DIET: DAT c SAP 1/10/2020
MULTIPLE STAB ANCILLARY:

WOUND 1) 5TH
DOQUES, MABINI JR ESCOBAR INTERCOSTAL SPACE CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
PARASTERNAL AREA, MEDICATION: 1/06/20 23.1 93 0.28 72.2 13.4 7.1 6.9 0.4 1049 82 27 333
25/M
RIGHT 2) 10TH 1/12/20 17.5 99 0.30 69.2 15.2 6.9 8.2 0.5 951 84 27 342
1/15/20 17.3 106 0.33 67.4 14.3 7.5 10.3 0.5 925 85 27 320
INTERCOSTAL SPACE
1/19/20 14.8 118 0.36 62 15 8.2 14.1 0.5 667 82 27 324
MAXILLARY LINE PLAN: For CXR tomorrow
CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOB:11/ 14/ 1994
1/06/20 133.10 4.57
DOA: 12/ 26/ 2019 1/12/20 61.60 137 4.26
1/19/20 62 136 3.96

CC: stab wound
28th hospital stay
bincey 1/12/20 12.40 31.60
1/19/20 13.20 54.50
ISOLATION
GS1
NITRAT
IVF: PLRS1L x 8HRS E
GSI INITIAL DX: DIET: DAT 1/13 LY Hazy 1.030 6 - - - - - - - - 4 1
ACUTE APPENDICITIS ANCILLARY:

BAJET BENJAMIN DE LEON MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
1.
58/F 1/16 13.1 148 0.43 85 8.8 3.4 1.5 0.4 246
MONITOR VS q4 and
record
DOB: NOV 20 1961 Monitor input and
output qshift
CHEMISTRY CREA BUN AMY LIPAS NA K C FAS GLU CHOOLE TRIGLY HDL AST ALT AL TP A/G CEA
DOA: 1/16/2020 E L P
PLAN: 1/19 78 139 3.51
MGH
1/16 25 32
CC: RUQ PAIN PT % INR CONTROL APTT CONTROL
7TH hospital day

IVF: PNSS 1L x12hrs
GS-1 INITIAL DX: DIET: DAT with SAP 1/22/20 8.4 107 0.32 60.8 28.0 6.2 4.5 0.5 359 85 29 340
ANCILLARY:
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRATE Leukocyte RBC WBC EPITH HYALI BACTERIA
BINUYAT, LOLITA IGNACIO CALCULOUS MEDICATION: 1/22 DY CLEAR 1/015 6 - TRACE + - +++ +++ - - 10-15 6-9 MANY FEW +++
CHOLECYSTITIS 1. Ketorolac
55/F
30mg/IV
2. 2. tramadol
50mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG FBS CHOLE TRIG HDL LDL FT4 TSH A/ CEA
G
DOB:12/14/1964 3. MgS04 2g/EC
1/22/20 51 137 3.35 1.80 5.80 5.52 0.40 0.40 4.26 1.11 2.22
4. tranexamic
DOA: 01/19/2020 acid 1g/IV PT % INR CONTROL APTT CONTROL
1/22/20 12.30 32.30
MONITOR VS q4 and
record
CC: abdominal pain Monitor input and
output qshift
4TH hospital stay PLAN:

Maintain NPO for E open
Cholecystectomy, IOC
probable CBDE
OVERFLOW
NITRAT
IVF: PLRS1L x 8HRS E
OF INITIAL DX: DIET: DAT 1/13 LY Hazy 1.030 6 - - - - - - - - 4 1
ANCILLARY:
PAROTID MASS
MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
MACANAN, NOEL VINASOY 2.
1/13 10 156 0.48 59 28 4.4 7.2 0.6 279
49/F MONITOR VS q4 and

record
Monitor input and
output qshift
DOB: DEC 21 1970 CHEM CREA BUN AMY LIPA NA K CL FAS CHO TRIG HDL LDL ALT TB TP A/ CEA
ISTRY SE GLU OLE LY G
DOA: 1/13/2020 PLAN:
MGH
CC: NECK MASS
HISTORY:
10th hospital day
luis
URO
IVF: on SR
URO INITIAL DX: DIET: Renal Diet 1/23/20 19.6 128 0.40 71 15 10 2.4 0.3 108 89 29 322
ANCILLARY:
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD NITRATE Leukocyte RBC WBC EPITH HYALI BACTERIA
DELA CRUZ MERCEDES, PACLEB PSEUDOANEURYSM MEDICATION: 1/23/20 Y CLOUDY 1.010 7.5 ++ ++++ - - - + - - 9-12 2-4 MANY - +++
S/P ARTERIO-VENOUS 5. Nicardipine
62/F FISTULA JULY 2019 drip
6. furosemide
40mg/IV CHEMISTRY CREA NA K HBAIC FT4 TSH FT3 FBS GLOBULIN AST ALT TB TP A/G CEA
DOB: 10/23/1957 7. ampicillin-

1/23/20 498 139 4.30 3.50 0.99 3.8788 <1.50 3.94
sulbactam
DOA: 01/20/2020 1.5g/IV
PT % INR APTT CONTROL
1/23/20 13.90 37.20
MONITOR VS q4 and
3rd hospital stay record
Monitor input and
output qshift
PLAN:
Secure 3 units platelet
concetrate properly
typed and crossmatched
to transfer once
available
Follow up Cardio
Clearance prior to OR
GS3

IVF: PNSS 1L x12hrs
GS-3 INITIAL DX: DIET: DAT with SAP 1/16/20 17 123 0.37 67 20 10 2 0.3 297 89 30 332
ANCILLARY:
NITRAT
E
GATCHALIAN, CHRISTYN KHEY INTRACRANIAL MASS MEDICATION: ½/2020 LY CLEAR 1.030 6.5 - - + - - + _ _ 7 25 29 0 446
ADIAZ INTRAVENTRICULAR 8. Cefuroxime
150mg/IV
17/M
9. Ranitidine 1
amp CHEMISTRY CREA BUN AMY LIPA NA K CL M CA ALBUM GLOBULIN AST ALT TB TP A/G CEA
10. Dexamethaso SE G IN
1/06/20 70.60 139 3.41 92
DOB:12/15/2002 ne 4g/IV
11. paracetamol PT % INR CONTROL APTT CONTROL
DOA: 01/02/2020 300mg/IV
MONITOR VS q4 and
record
CC: abdominal pain Monitor input and
output qshift
21th hospital stay PLAN:

NEURO MGH
jesserene
Awaiting MRI result
DISCHARGES
CATAGGATAN
LAURETA
ATTABAN
CAPINLAC
LIZARDO
BAJET
MACANNAN
AGRIAM
JARA

Trauma Male A: General Surgery: Team I Dr. Tamani/Lingan/Aguisanda/Baculi/Casco/ Bulusan

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Trauma Male A: General Surgery: Team I Dr. Tamani/Lingan/Aguisanda/Baculi/Casco/ Bulusan

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GENERAL SURGERY: TEAM I

DR. TAMANI/LINGAN/AGUISANDA/BACULI/CASCO/ BULUSAN/ padilla/soriano/ravivarma/raveendran/nagui/shanmugam/navalta/felix

JANUARY 22, 2020

run for 15 PT INR % Control PTT Control

DOI: 01/06/20 PLAN:

34/M MULTIPLE PHYSICAL MEDICATION:

CC: VA TRAMADOL 50MG/ IV

TOI: 7:30 PM MGH 1/21/20 137.60 3.36

2nd Hospital stay

DOB: 10/24/2019 SKULL FRACTURE Sulbactam 162.5g

POI: CABAGAN ISABELA PLAN:

3rd Hospital day

TM A INITIAL DIAGNOSIS IVF: D5LRS 1L X 8 HRS NITRAT

8th HOSPITAL STAY

ACUTE EPIDURAL ANCILLARY:

13th HOSPITAL DAY PLAN: 1/21/20 137.80 4.33

Refer Back prior to

TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT

CORTEZ HEMATOMA, ANCILLARY:

5th HOSPITAL DAY

TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT

INJURY SECONDARY ANCILLARY:

CC: VEHICULAR ACCIDENT RIGHT PARIETAL, Mannitol 100cc/IV

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

CC: VEHICULAR ACCIDENT PLAN:

Daily wound care

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

TEMPOROPARIETAL +10meqs KCL

7TH Hospital stay

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

DOA: 01/20/20 FRONTOTEMPOROPA with BP precaution

PLAN: 1/18/20 136 3.49

TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

Salbutamol + Iprat neb

1/18/20 136 3.49

TM-B INITIAL DX: IVF: D5LRS 1L X 12 HRS NITRAT

HEMATOMA, RIGHT Ketorolac 30mg/IV

PT INR % Control PTT Control

1/18/20 15.50 40.10

MULTIPLE PHYSICAL ANCILLARY:

DOA: Jan 18 2020 SECONDARY TO PLAN:

NOI: Vehicular accident

POI: CLAVERIA, CAGAYAN

1/15/20 13.50 27.10

8th HOSPITAL DAY

MULTIPLE STAB ANCILLARY:

record 1/09/20 3.63 142.61 98.64

NOI: STAB WOUND

POI: LASAM, CAGAYAN

13th HOSPITAL DAY

TF-B INITIAL DX:

POI: Mallig Isabela

3RD HOSPITAL DAY

MULTIPLE STAB ANCILLARY:

DOA: 12/ 26/ 2019 1/12/20 61.60 137 4.26

1/19/20 62 136 3.96

bincey 1/12/20 12.40 31.60

1/19/20 13.20 54.50

ACUTE APPENDICITIS ANCILLARY:

CC: RUQ PAIN PT % INR CONTROL APTT CONTROL

7TH hospital day

CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh

4TH hospital stay PLAN: