ILOCOS TRAINING AND REGIONALMEDICALCENTER

City of San Fernando, La Union

SERVICE 2

DR. ESTANDIAN/CORTEZ/DE GUZMAN/MONIS/VIDAL/CASTANEDA/BALANON/CASTILLO/DIPESH/MANGABAT/ABAYA/MANZON/ADHEEP/YADAV

GURION/DEPALOBOS/IGUID/SATODIYA/SHETH

MEDICAL WARD 1 CENSUS

March 13, 2018

MEDICAL WARD 1
Admission Information Problem List Medications Notes and Laboratories
OBRA, Rodolfo, Macato Admitting Diagnosis: Medications: IVF: PLRS 1L x 16
75/F/M Anemia Secondary to Upper 1. Omeprazole 40mg IV OD Diet: Soft Diet
San Juan, La Union Gastrointestinal Bleeding 2. Sucralfate 1gm QID
04-01-1942 secondary to Bleeding Peptic 3. Furosemide 20mg IV every BT CBC 3/8
2018-0006926 Ulcer Disease Hgb 141
Hct 42.9
DOA: 03-03-2018 PWI: WBC 11.71
HD: 9th N 76.3
L 15.3
RIC: Dr. ABAYA
Mono 2.9
CCIC: JI Depalobos
Eo 4.8
Baso 0.7
Plt 252
BLOOD type O+
Pro Time
INR

Na K BUN Crea iCa

3/7 141 3.9

Tot. Protein Albumin Globulin AG Ratio

3/6 52.9 29.0 23.9 1.2
ABAN, Leone, Rances Admitting Diagnosis: Medications: IVF:PNSS 1L x 10gtts/min
48/F/M CVD probably Bleed; HPN II 1. ASA 80mg/tab OD Diet: Low Salt Low Fat
Bauang, La Union 2. Clopidogrel 75mg/tab OD
11/07/1969 PWI: 3. Rosuvastatin 20mg/tab ODHS CBC 3-10
2003-0107226 CVD Infarct; HPN, uncontrolled 4. Irbesartan + HCTZ 1tab OD in Hgb 113
AM Hct 39.9
DOA: 03-07-2018 5. Amlodipine 10mg/tab OD in WBC 10.83
HD:5th PM
N 78.8
L 8.4
RIC: Dr. ABAYA
Mono 5.1
CCIC: JI Depalobos
Eo 7.1
Baso 0.6
Plt 179
BLOOD type
Pro Time
INR

FBS TC Trig HDL LDL

03-10-2018 5.0 3.3 0.29 0.9 2.34

Gram Stain (Cervical Discharge)

03-10-2018 WBC +2
Epithelial Cells +2
Gram-Negative Bacilli +4
KOH (Cervical Discharge)
03-10-2018 NO Fungal Elements seen

OCASION, Jocelyn, Avecilla Admitting Diagnosis: Medications: IVF: PNSS 1L x 16 hours

57/F/W Cerebrovascular Disease 1. Losartan 50mg OD Diet: OF of 1,800kCal in 6 feedings
Balaoan, La Union probably bleed 2. Tranexamic Acid 500mg IV q8.
01-18-1965 3. Amlodipine 10mg OD CBC 3-10-18
2018-0007892 PWI: 4. Mannitol 150 cc IV bolus q6 Hgb 147
with BP prec Hct 44
DOA: 03-10-2018 5. Paracetamol 600 mg IV q6 RTC WBC 12.56
HD:4th
N 91.3
L 6.9
RIC: Dr. ABAYA
Mono 1.5
CCIC: JI Depalobos
Eo 0.1
 Baso 0.2
Plt 285
BLOOD type 0+
Pro Time 12.5
INR 0.99

FBS TC Trig HDL LDL HBA1

C
03-12-2018 6.37 5.2 1.04 1.0 3.69 5.6%

MEJIA, Lealy, Chua Admitting Diagnosis: Medications: IVF: Heplock

39/F/S Chronic Kidney Disease 1. Furosemide 40mg q8 Diet: Uremic Diet at 1,800 kCal; Limit OFI to <2L/day
Rosario, La Union Secondary to Diabetes 2. NaHCO3 2 tabs TID
08-06-1978 Nephropathy 3. CaCO3 2 tabs BID CBC 3-11-18 3-11-18
2018-0007907 Hgb 79 95
PWI: Hct 23.8 28.9
DOA: 3-10-2018 WBC 6.80 7.04
HD: 4th N 64 81.3
L 23.2 14.2
RID: Dr. ABAYA
Mono 5.7 2.7
CCIC: JI Depalobos
Eo 6.7 1.4
Baso 0.4 0.4
Plt 249 254
BLOOD type B+
Pro Time
INR

Na K BUN Crea Mg PO4

3-11 141.7 5.57 33.05 619.25 1.054 2.18

ABGs 3-11-18
pH 7.311
pCO2 35.7
pO2 68.5
BEecf -7.76
HCO3 17.6
tCO2 18.7
sO2 90.9%
 HBA1c
3-11-18 5.5%

HBsAg
3-11-18 Non-Reactive
Anti-HCV
3-11-18 Non-Reactive

AGAMENG, Danilo, Buyagao Admitting Diagnosis: Medications: IVF: PNSS 1L x 16 hours

56/M/M Cerebrovascular Disease R/O 1. Aspiring 80mg/tab OD Diet:Low Salt Low Fat 1800 kCal
Candon, Ilocos Sur Infarct 2. Clopidogrel 75mg/tsb OD
02-05-1962 3. Rosuvastatin 20mg/tab ODHS CBC 3-11-18
2018-0007898 PWI: 4. Paracetamol 500mg/tab q6 Hgb 112
PRN for headache Hct 33.5
DOA: 03-10-2018 5. Mupirocin Ointment BID on WBC 10.08
HD:4th affected Area N 67.3
L 21.3
RIC: Dr. MANGABAT
Mono 5.5
CCIC: JI Depalobos
Eo 5.2
Baso 0.7
Plt 328
BLOOD type
Pro Time 11.9
INR 0.94

Na K BUN Crea
3-11-18 141 4.09 3.86 44.11

FBS TC Trig HDL LDL

03-11-2018 6.05 4.6 0.25 0.7 3.80

URINALYSIS 03-11-2018
Color Light Yellow
Trans Turbid
WBC 23-25
RBC 0-2
 GLU Negative
CHON Positive
pH 6.0
Sp.gr 1.025

RACCA, Julius, Valdez Admitting Diagnosis: Medications: IVF: D5NSS 1L x 16 hours

38/M/M Nasopharyngeal Carcinoma 1. Ranitidine 50mg IV q12 Diet: DAT with SAP at 1900 kCal
San Fernando, La Union Stage IV; Community Acquired 2. Tramadol 50mg IV q6
07-20-1979 Pneumonia – Moderate Risk, 3. Ketorolac 30mg IV q8 CBC 03-08-18 03-10-18 03-10-18
2003-0015473 T/C HAP; Protein Energy 4. Lactulose 30cc ODHS Hgb 110 104 95
Malnutrition 5. NAC 600mg.tab in ½ glass Hct 29.9 28 26.1
DOA: 03-08-2018 water ODHS WBC 15.35 15.98 16.13
HD:6th PWI: 6. FeSO4 + FA 1 tab BID
N 90.4 88.8 69.8
7. Domperidone 10mg/tab TID
L 7.6 6.0 6.6
RIC: Dr. MANGABAT 8. Azithromycin 500mg/tab OD
Mono 1.2 3.0 2.6
CCIC: JI Depalobos 9. Ceftriaxone 2gms in 90cc PNSS
to run for 1 hour q24 Eo 0.6 2.0 20.6
10. Salbutamol + ipratropium neb Baso 0.2 0.2 0.4
q8 Plt 30.8 369 369
BLOOD type A+
Pro Time
INR

Na K BUN Crea AST ALT

3-8-18 101 3.7
3-9-18 105
3-10-18 122.9

Tot. Protein Albumin Globulin AG Ratio

3-8-18 73.7 42.4 31.3 1.4:1.0

BULSECO, Sherwin, Centeno Admitting Diagnosis: Medications: IVF:PNSS 1L x 12 hours

30/M/M CVD Infarct probably RMCA; 1. ASA 80mg/tab OD Diet: Low Salt Low Fat
Santo Tomas, La Union Cardiac Dysrrhythmia 2. Clopidogrel 75mg/tab OD
11-30-1987 3. Rosuvastatin 20mg/tab ODHS CBC 03-07-18 03-08-18 03-10-18
2018-0007558 PWI: 4. Metoclopramide 10mg IV PRN Hgb 139 145
for N/V Hct 42.9 45.7
DOA: 03-07-2018
HD:7th WBC 14.86 13.09
N 73.9 71.4
RIC: Dr. MANGABAT L 17.9 16.5
CCIC: JI Depalobos Mono 7.5 10.8
Eo 0.4 0.8
Baso 0.3 0.5
Plt 290 290
BLOOD type A+
Pro Time 17.1
INR 1.37

Na K BUN Crea iCa Mg

3-8-18 138 4.41 4.18 60.40 1.71 0.852
3-10-18 137 4.1

URINALYSIS 03-08-2018
Color Dark Yellow
Trans Clear
WBC 0-1
RBC 0-1
GLU Negative
CHON Negative
pH 6.5
Sp.gr 1.030

DUCULAN, Lorma, Catap Admitting Diagnosis: Medications: IVF: PNSS 1L x KVO

71/F/W DM Type 2, uncontrolled; 1. Diet: DM Diet
San Fernando, La Union Hyperglycemic Emergency;
05-20-1956 Ischemic Heart Disease Atrila CBC 03-07-18 03-11-18
2010-0028307 Fibrillation in Controlled Hgb 123 112
Ventricular Response S/P Non- Hct 37 35.3
DOA: 03-07-2018 ST Elevation Myocardial WBC 11.74 5.14
HD:7th Infarction N 91.7 64.3
L 4.3 25.2
RIC: Dr. MANGABAT PWI:
Mono 2.9 7.4
CCIC: JI Depalobos
Eo 1.1 2.8
Baso 0.0 0.3
Plt 143 111
BLOOD type AB +
Pro Time
INR

Na K BUN Crea
3-7-18 136 3.8 18.61 148.10
3-7-18 3.90
3-8-18 3.06
3-8-18 3.07
3-8-18 3.0
3-11-18 144.4 3.21

Cardiac Panel
Troponin I (3/207/2018) Negative

GRAM STAIN - Sputum

03-11-2018 WBC: +1
Epithelial Cells: +2
Gram-Negative Bacilli: +1
KOH - Sputum
03-11-2018 No Fungal elements seen.

Repeat Chest X-Ray (02-15-18)

Bilateral PTB
Pulmonary Arterial Hypertension
Cardiomegaly. Atherosclerotic Aorta.
Bilateral pleurodiaphragmatic adhesion.

ABGs 3-7-18
pH 7.475
pCO2 32.9
pO2 162.5
BEecf 0.08
HCO3 23.7
tCO2 24.7
sO2 99.6
MIQUE, Jesus, Ramos Admitting Diagnosis: Medications: IVF:PLRS 1L + 40 meqs KCl TRF for 12 hours x 2 doses
68/M/M Hypokalemia, cause to be found 1. KCL tablets 2 tablets q4 x 5 Diet: DAT
Balaoan, La Union doses
12/25/1949 PWI: 2. Amlodipine 10mg/tab OD CBC 3/11 3/12
2018-0007918 3. Salbutamol + Ipratropium Neb Hgb 134 132
q12 Hct 41.7 40.7
DOA: 03-11-2018 4. Formoterol + Budesonide 2 WBC 21.58 18.31
HD: 3rd puffs BID
N 77.2 80.3
5. Tiotropium 10mg 1 puff OD
L 10.2 7.1
RIC: Dr. MANGABAT 6. Azithromycin 500mg/tab OD
Mono 11.3 9.6
CCIC: JI Depalobos 7. NAC 600mg/tab in ½ galss
water ODHS Eo 1.2 2.8
8. Ceftriaxone 2 gms + 90cc PNSS Baso 0.1 0.2
to run for 1 hour q24 Plt 331 317
BLOOD type O+
Pro Time
INR

Na K Cl BUN Crea
3-11-18 137.6 2.16 83.6 3.44 39.16
3-11-18 2.42
3-12-18 2.6
3-12-18 2.7

ABGs 3/11
pH 7.573
pCO2 52.5
pO2 38.7
BEecf 21.83
HCO3 47.4
tCO2 49
sO2 85

VILLANUEVA, Agapito JR., Admitting Diagnosis: Medications: IVF: D5NSS 1l x 8 hours

Collado Chemical Ingestion, Non- 1. Metoclopramide 10mg IV q8 Diet: NPO
26/M/S accidental; Major Depressive PRN for N/V
Bacnotan, La Union Episode with Psychotic Features 2. Ranitidine 50mg IV q8 CBC 3/13
03-14-1991 T/C Major Depressive Disorder 3. Tramadol 50mg IV q6 Hgb 152
2018-0008137 4. Diazepam 5mg IV q8 Hct 45.2
PWI: WBC 9.82
DOA: 3-13-2018 N 75.6
HD: L 18.9
Mono 3.9
RIC:
Eo 1.5
CCIC: JI Depalobos
Baso 0.2
Plt 367
BLOOD type
Pro Time 12.2
INR 0.97

Na K Cl BUN Crea AST ALT

3-13-18 146.4 4.73 116.8 2.29 68.46 31.2 51.8

SUPNET, Eliuterio Admitting Diagnosis: Medications: IVF: PNSS 1L x 8 hours

49/M/M CVD Bleed, HTN 1. Mannitol 175cc q6 Diet: OF at 1,900kCal
Caba, La Union 2. Furosemide 40mg after each
2018-0008152 PWI: Mannitol CBC 3/13
3. Omeprazole 40 mg IV OD Hgb 149
DOA: 3-13-2018 4. Losartan 50mg BID Hct 48.5
HD: 5. Amlodipine 10mg OD WBC 13.26
N 71
RIC:
L 23.6
CCIC: JI Depalobos
Mono 2.8
Eo 2.2
Baso 0.4
Plt 294
BLOOD type B+
Pro Time 11.1
INR 0.88

Na K BUN Crea AST ALT

3-13-18 143 3.4 3.93 81.25 25.3 17.0
NIEVERAS, Gloria, Redulfin Admitting Diagnosis: Medications: IVF: PNSS 1L x KVO
61/F/M Anemia, ETBD; PUD R/O 1. Omeprazole 40mg IV q12 Diet: DAT with SAP
Bangar, La Union Malignancy 2. HNBB 10mg IV q8
04-03-1956 CBC 3/13
2002-0118688 PWI: Hgb 66
Hct 21.3
DOA: 03-13-2018 WBC 11.62
HD:
N 88.1
L
RIC:
Mono 2.5
CCIC: JI Depalobos
Eo 0.8
Baso 0.3
Plt 520
BLOOD type
Pro Time
INR

URINALYSIS 03-13-2018
Color Straw
Trans Clear
WBC 0-6
RBC 0-5
GLU Negative
CHON Negative
pH 6.0
Sp.gr 1.030

CARA, Virgilio, Dulay Admitting Diagnosis: Medications: IVF: PNSS 1L x 6 hours

73/M/W Abdominal Aortic Aneurysm 1. Diet: Soft Diet
Rosario, La Union probably leaking; Hypovolemic
04-22-1944 shock secondary; Anemia CBC 3/13
2018-0008196 secondary Hgb 67
Hct 20.7
DOA: 03-13-2018 WBC 12.80
HD:
N 91.2
L 4.9
RIC: Mono 3.3
CCIC: JI Depalobos Eo 0.5
Baso 0.1
Plt 321
BLOOD type B+
Pro Time 12.9
INR 1.02

Na K Crea
3-13-18 133 5.5 302.96

APILADO Admitting Diagnosis: Medications: IVF: PNSS 1L x 16 hours

57/M/M Cerebrovascular Disease 1. Metoclopramide 10mg IV q8 Diet: OF of 1,590 kCal
San Fernando, La Union probably Infarct, RMCA PRN for N/V
07-13-1960 2. Omeprazole 20mg IV BID CBC 03-10-18
2011-0013606 PWI: 3. Clopidogrel 75mg/tab OD Hgb 113
4. Aspirin 80mg/tab OD Hct 36
DOA: 03-10-2018 5. Rosuvastatin 20mg/tab ODHS WBC 8.96
HD: 4th
N 75.8
L 21.2
RIC: Dr. MANZON
Mono 2.6
CCIC: JI Depalobos
Eo 0.3
Baso 0.1
Plt 271
BLOOD type
Pro Time 13.0
INR 1.03

Na K
3-10-18 137.1 4.25

FLORENDO, Francis, Rimando Admitting Diagnosis: Medications: IVF: D5W x KVO

69/M/M Pulmonary Congestion 1. Furosemide 40mg IV q8 Diet: Low Salt Low Fat; Low Purine
Naguilian, La Union secondary to Hypertensive 2. Irbesartan 150mg OD
10-11-1948 Cardiovascular Disease; 3. Metoprolol 50mg OD CBC 03-13-18
2009-0011348 Coronary Artery Disease, Atrial 4. Rosuvastatin 20mg ODHS Hgb 90
Fibrillation on Controlled 5. NaHCO3 650mg BID Hct 30.6
DOA: 03-13-2018 Ventricular Response; 6. FeSO4 + FA BID WBC 7.46
HD: Hypertension II; Chronic Kidney 7. CaCO3 OD N 82.1
Disease 8. Tramadol 50mg IV q6 L 13.5
RIC: 9. Paracetamol 300mg q4 PRN for Mono 3.1
CCIC: JI Depalobos PWI: fever Eo 0.7
Baso 0.6
Plt 138
BLOOD type A+
Pro Time 12.2
INR 0.97

ASPURIA, Zenaida, Madriaga Admitting Diagnosis: Medications: IVF:

55/F/M Chronic Kidney Disease Stage V 1. Furosemide 40mg IV q12 Diet:
Agoo, La Union secondary to Hypertensive 2. NaHCO3 2 tablets TID
11-26-1962 Nephropathy 3. EPO 4,000 units SQ 2x a week CBC 03-13-18
2005-0009901 Hgb 84
PWI: Hct 26.6
DOA: 03-13-2018 WBC 18.45
HD:
N 56.8
L 34.9
RIC:
Mono 3.3
CCIC: JI Depalobos
Eo 4.6
Baso 0.4
Plt 543
BLOOD type
Pro Time
INR

Na K BUN Crea
3-13-18 141.7 6.37 15.97 594.88

MARQUEZ, Remedios, Balanon Admitting Diagnosis: Medications: IVF:

82/F/M Acute Gastroeneteritis 1. Rosuvastatin 20mg ODHS Diet:
San Fernando, La Union S/P CVD Infarction vs 2. Amlodipine 10mg OD
01-18-1936 Hemorrhage; DMT2, controlled 3. NaHCO3 650mg TID
2010-0017593 4. Furosemide 49mg OD
5. CaCO3 + Vitamin D OD
DOA: 03-13-2018 6. Omeprazole 40mg OD
HD: 7. FeSO4 + FA BID

RIC:
CCIC: JI Depalobos