SERVICE 2
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
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
Na K BUN Crea
3-11-18 141 4.09 3.86 44.11
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
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
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
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
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
Na K Crea
3-13-18 133 5.5 302.96
Na K
3-10-18 137.1 4.25
Na K BUN Crea
3-13-18 141.7 6.37 15.97 594.88
RIC:
CCIC: JI Depalobos