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 18, 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 1LxKVO E
TM-A INITIAL DX: DIET: DAT with SAP 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/B
DOA: 01/06/20 Ipratropium lin E Y G 2
neb q6 1/11/20 28 27.80 60 94 221. 55 1.0 86.8/
3 36.2
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
HISTORY: gtts/min PT INR % Control PTT Control
1/11/20 13.20 1.06 90.4 34.3

NOI: VA
MONITOR VS q4 and
TOI: 6:30AM record
Monitor input and
POI: PENABLANCA, CAGAYAN output q shift
DOI: 01/06/20 PLAN:

D/C ALV meds
12th hospital day Continue celecoxib
Facilitate Chest UTZ
Novi
NITRAT Leukocy
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 8hr E te
TM-A INITIAL DX: DIET: NPO temporarily 1/18
DARK
TURBID 1.025 6.5 ++ - +++ - - +++ - - >100 0-3 RARE - ++
RED
MEDRAZO, CHRIS KYLE OLIVAS PENTRATING INJURY ANCILLARY:

RIGHT LOWER
7/M QUADRANT AREA MEDICATION:
CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
1. Ampicillin
DOB:10/11/2012 1/18 14.6 104 0.31 71 15 12 0.8 0.3 371
sulbactam
DOA: 01/18/20 1g/IV q8
2. ketorolac
CC: PENETRATING INJURY 30mg/IV
3. tramadol
50mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
1ST hospital day 4. Tranexamic

1/18 136 4.48
acid
135/mg/IV
PT INR % Control PTT Control
5. Vitamin K
qg/IV
MONITOR VS q4 and
record
Monitor input and
output q shift
PLAN:
Start tranexamic acid
500mg/IV
Insert IFC with urine bag
repeat CBC
NITRAT Leukocy
UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD RBC WBC EPITH HYALI BACTERIA
IVF: PNSS 1L x 8hr E te
TM-A INITIAL DX: DIET: NPO temporarily
ARBOLANTE, MICHEAL GAMATA MULTIPLE ANCILLARY:

PHYSICALINJURY
27/M SECONDARY TO MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
VEHICULAR 6. Ampicillin 1/18 10.7 130 0.41 79 12.8 6.8 0.8 0.6 329
DOB:04/29/1992
ACCIDENT, CEREBRAL sulbactam
DOA: 01/18/20 CONCUSSION TO 1g/IV q8
CONSIDER VASCULAR 7. ketorolac CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
CC: VEHICULAR ACCIDENT INJURY 30mg/IV

1/18 85 138 4.57
8. Omeprazole
NOI: VEHICULAR ACCIDENT 40mg/IV
TOI: 6PM MONITOR VS q4 and 1/18 15.20 39.20

record
DOI:1/18/20 Monitor input and
output q shift
POI: TUAO CAGAYAN
PLAN: Daily wound care
1ST hospital day
NITRAT
IVF: PNSS 1L x KVO E
TM-A INITIAL DX: DIET: DAT
Pneumohemothorax
ANCILLARY: CTT output
left secondary to stab
CARDENAS, DARNLIE CASTRO 400cc
wound T10
33/M MEDICATION:
S/P CTT Left 1/11/20 16.0 68 0.20 88.2 5.7 5.8 0.1 0.2 150 65 22 342
1. Ampicillin- 1/14/2020 7.9 128 0.41 70.5 10.4 9.9 8.8 0.4 256 73 23 316
DOB:01/24/2020 Sulbactam 1.5g IV
q8
DOA: 01/11/2020 2. omeprazole
40mg/IV
CC: STAB WOUND 3. Ketorolac 30mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
MONITOR VS q4 and 1/11/20 133 4.39

record
HISTORY: 1/14/20 137 4.03
PLAN: PT % INR CONTROL APTT CONTROL

NOI: STAB WOUND
Continue incentive
spirometry
TOI: 11PM
For chest xray PA today
POI: APARRI CAGAYAN
DOI: 01/11/2020
6th Hospital day
BEV
NITRAT
TM-A INITIAL DX: DIET: DAT with SAP 1/17 LY CLEAR 1.010 6.5 - - - - - + - - 0-2 0-1 0 0 +
GALLARDO, NICK ALAGANO MULTIPLE PHYSICAL

ANCILLARY: CTT output
INJURY SECONDARY
41/M 400cc
TO VEHICULAR CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT, TRIPOD MEDICATION: 1/17 17.2 119 0.38 89.2 5.7 4.7 0.1 0.3 281 63 20 317
DOB:05/24/78
FRACTURE, RIGHT 4. Ampicillin-
DOA: 01/16/2020 Sulbactam 1.5g IV
q8
CC: VEHICULAR ACCIDENT 5. omeprazole
40mg/IV
6. Ketorolac 30mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
HISTORY: MONITOR VS q4 and
record
NOI: VA
TOI: 10PM
For Facial CT scan with
3D enhancement
POI: ENRILE CAGAYAN
DOI: 01/16/2020
2nd Hospital day

Trauma Male B
NITRAT
IVF: PNSS 1L X KVO E
TM-B INITIAL DX: DIET: DAT with SAP 1/102020
MULTIPLE PHYSICAL ANCILLARY:

INJURY SECONDARY MEDICATION: Ampicillin-
PITA, SIMEON TO VEHICULAR Sulbactam 1.5g/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT , Omeprazole 40mg/IV 1/09/20 6.7 69 0.20 73.0 13.9 6.7 6.1 0.3 152 93 32 340
CONTUSION Tranexamic Acid
HEMATOMA, LEFT 500mg/IV
FRONTOTEMPOROPA Ketorolac 30mg/IV
DOB:06/12/20 RIETAL, FEMORAL Cefoxitin 1g/IV
FRACTURE LEFT Gentamycin 240mg/IV CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOA: 01/07/20 Mannitol 100c/IV
1/07/20 124.90 141.40 4.13
CC: VA
MONITOR VS q4 and PT INR % Control PTT Control
11th HOSPITAL DAY record
Monitor input and 1/07/20 12.40 25.80
output q shift
Varma
PLAN:
For repeat Chest XRAY
PA
Refer Back to Ortho for
TOS
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
4th HOSPITAL DAY
PLAN: P PT INR % Control PTT Control
Daily wound care

Bincey continue meds 1/13//20 13.30 30.30
decrease manitol to 75cc

q8 x 3 cycles then d/c
Facilitate Correction of
potassium
NITRAT
IVF: D5NSS 1LX 8hours E
TM-B INITIAL DX: DIET: NPO
ANCILLARY: S/D Nirpid ½

L x 24hours
UMAYAM, CARLO MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
1/18 6.2 115 0.34 81 7.6 9.1 1.6 0.3 190 79 27 335
MONITOR VS q4 and
record
Monitor input and
DOB:Oct 17 1972 output q shift
DOA: 09/22/2019 PLAN:
RPT CBC 1/19 141 3.93
CC: Increase Omeprazole
40mg/IVq12
TM-B INITIAL DX: IVF: PNSS 1L X 8 HRS NITRAT

E
PEREZ, JACK BARROGA MULTIPLE PHYSICAL ANCILLARY:
INJURY SEC TO VA TO
28/M CONSIDER LEFT LEG MEDICATION:
FRACTURE, Ampicillin-Sulbactam
DOB: 03/3/1991 1.5g TIV q8
LACERATED LEFT
FOOT Ketorolac 30 mg IV q8
DOA: 01/15/20 1/15/20 9.3 80 0.25 81.5 9.5 8.8 0.0 0.2 214 74 24 320
PRN for pain
CC: VA Omeprazole 40 mg TIV
q24
NOI: VA
Monitor VS q1 and
TOI: 12 AM record CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
Monitor I & O qshift and
POI: LALLO, CAGAYAN 1/15 142.7 3.47
record /20
PLAN:
DOI: 1/15/20 May transfer to ORTHO PT INR % Control PTT Control
rd
1/15/2020 15.30 1.22 70.2 26.7
3 HOSPITAL DAY
TM-B INITIAL DX: IVF: PNSS 17-18gu/min NITRAT

DIET: DAT 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
1.5g TIV q8
DOB: 05/8/2013 Ketorolac 30 mg IV q8 1/18 7.6 103 0.30 62 31 5.4 0.4 0.7 344 80 28 344
PRN for pain

DOA: 01/18/20 Omeprazole 40 mg TIV
q24
CC: FALL
Monitor VS q2 and CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
NOI: FALL record ISTRY SE MIN LIN G
Monitor I & O qshift and 1/18 140 4.26

TOI: 10PM /20
record
POI: ILAGAN ISABELA PLAN: PT INR % Control PTT Control
Increase mannitol 1/18/2020 14.50 39.80
DOI: 1/18/20 150ccq6 +paracetamol

300mg/IV q6 for pain
1ST HOSPITAL DAY
NITRAT
IVF: PNSS 1L X 8hr E
TM-B INITIAL DX: DIET: General liquids

INJURIES SECONDARY MEDICATION:
BAYUGA,DEMY MACATUGGAL TO VEHICULAR CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACIDENT; BLUNT 1/15//2020 23 147 0.42 76 12 11 0.1 0.1 214
35/M
ABDOMINAL MONITOR VS q4 and 1/16/2020 19 144 0.41 80 8.3 11.6 0 0.2 208
TRAUMA record
Monitor input and
DOB:12/13/1984 output q shift
DOA: 01/15/2020 PLAN:
May TOS to Ortho 1/16 138 3.90
CC: VA service
for direct OR: PT INR % Control PTT Control
NOI: VEHICULAR ACCIDENT Debridement
Arthrotomy Knee 1/14 13.60 24.10
TOI: 9PM Secure 1 unit PRBC
POI: ABULUG, CAGAYAN
DOI: 1/15/2020
3nd HOSPITAL DAY
NITRAT
IVF: PNSS 1L x 16hr E
TM-B INITIAL DX: DIET: DAT with SAP

INJURY SECONDARY MEDICATION:
ENRIQUEZ, RICARDO GABRIEL TO VEHICULAR 9. CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; MULTIPLE
50/M
RIB FRACTURE, 3RD-
5TH RIB RIGHT PLAN:
for repeat CXR tomorrow
DOB: 07/25/1969
DOA: 01/16/2020 CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
CC: VEHICULAR ACCIDENT

PT % INR CONTROL APTT CONTROL
HISTORY:
NOI: VA
TOI: 1AM
POI: SOLANA CAGAYAN
DOI: 01/16/20
2nd hospital day

DIET: DAT with SAP E
CABANERO, NARCISO PASCUA TRAUMATIC 1/102020
SUBARACHNOID MEDICATIONS:
69/M HEMORRHAGE Ampicillin- Sulbactam
SEC.TO VEHICULAR 1.5g/ IV q8
DOB: 04/21/1950
ACCIDENT Omeprazole 40mg IV OD CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOA: 01/13/20 Ketorolac 30 mg IV q8 x 1/14/20 25.1 128 0.38 88.2 3.7 8.7 0.1 0.2 230 90 31 338
3 doses
CC: Vehicular accident Gentamycin 240mg/ IV
OD
NOI: VA
PLAN: CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
TOI: 10am ISTRY SE MIN LIN G
WOF:
1/14 136.40 3.71
Neurodeterioration
DOI: 1/13/20 /20

POI: tuguegaro city
1ST HOSPITAL DAY

DIET: Low salt Low fat 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
CC: LOC Ketorolac 30 mg/IV q8
PRN for pain CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
Kcl drip: 900cc PNSS +
NOI: FALL 10 meqs Kcl x 1 hr x 2 1/14/20 136.40 3.71
cycles 1/18/20 136 3.49

TOI: 7 PM
PLAN: PT INR % Control PTT Control
DOI: 1/06/20
Increase mannitol to
4th Hospital stay 150cc/IV
Give ketorolac 30mg/IV
request for CBC NA, K
TM-B INITIAL DX: IVF: D5LRS 1L X 8 HRS NITRAT

DIET: NPO temporarily E
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
DOA: 01/18/2020 HEMATOMA, RIGHT Ketorolac 30mg/IV

FRONTAL SKULL
CC: INGESTION OF ZONROX FRACTURE FRONTAL
AREA PLAN:
1ST Hospital stay Start Mannitol 100cc CHEMISTRY CREA BUN AMY LIPAS NA K MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
E
now then 75cc q6 1/18/20 135 3.85
WOF Neurodegeneration
1/18/20 15.50 40.10
TM-B INITIAL DX: IVF: D5LRS 1L X 8 HRS NITRAT

DIET: NPO E
SUAREZ, ERNIE BAYONA CAUSTIC INGESTION
(ZONROX) MEDICATION:
50/M
DOB: 06/27/69 1/14/20 25.1 128 0.38 88.2 3.7 8.7 0.1 0.2 230 90 31 338
PLAN:
DOA: 01/15/2020 may have general liquids
please give paracetamol
CC: INGESTION OF ZONROX 300mg/IV q4 as needed
for temperature >37.7c
3nd Hospital stay Advised TSB CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
1/14 136.40 3.71
/20
BURN
BURN INITIAL DX: IVF: PNSS 1L x 8h NITRAT
DIET: NPO temporarily E
TUMALIUAN, JHON CHRISTOPHER ELECTRICAL INJURY;
NO CUTANEOUS
GACIAS BURN MEDICATION:
Cefoxitin 1g/IV q12
15/M Metronidazole 500mg/
IV q8
DOB: 06/14/2004 Omeprazole 40mg/IV
OD
DOA: 01/18/20 Ketorolac 30 mg/IV q8
Vit. K amp IV q8
CC: ELECTRICAL BURN
CHEMISTRY CREA BUN AMY NA K CL MG CA CKMB TROP I AST ALT TB TP A/G CEA
NOI: ELECTRICAL BURN PLAN:
Insert IFC with UB 1/18 68.40 138.40 3.75 13 NEGATIVE
TOI: 3PM refer to Pedia
DOI: 1/18/20
POI: TUGUEGARAO CITY
1ST Hospital stay
AISLES RIGHT
AR INITIAL DX: IVF: PNSS 1L x 8h NITRAT
DIET: Diet for age E
LIGUTAN, MA. MIKA ELLAH DIFFUSAL AXONAL
TALLADTAD INJURY SECONDARY MEDICATION:
TO FALL Cefoxitin 1g/IV q12
3/M
Metronidazole 500mg/
DOB: 03/26/2016 IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Omeprazole 40mg/IV 1/16 43.6 74 0.24 74 19 2.6 2.7 0.5 953 49 15 305
1/17 15.6 72 0.24 49.1 40.6 5.9 3.9 0.5 755 50 15 304
DOA: 01/16/20 OD 1/18 15.8 106 0.34 34 52 7 5 0.7 734 57 18 311
Ketorolac 30 mg/IV q8
CC: FALL Vit. K amp IV q8
NOI: FALL PLAN:

CHEMISTRY CREA BUN AMY LIPA NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
For repeat cranial CT SE
TOI: 12:30PM scan 1/16 138
WOF;
DOI: 1/16/20
neurodegeneration
POI: PENABLANCA 1/16 16 30.50
CRITICAL CARE ROOM

NITRAT
IVF: PNSS 1L x 12hrs E
CCR INITIAL DX: DIET:

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 MONITOR VS q2 and
HEMORRHAGE record 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 Monitor input and 59 145 3.88
VEHICULAR output qshift PT % INR CONTROL APTT CONTROL

CC: Vehicular Accident ACCIDENT 1/18/2020 18.70 35.60
PLAN:
NOI: Vehicular accident
TOI: 3pm
DOI: 1/18/20
POI: CLAVERIA, CAGAYAN
1ST HOSPITAL DAY
NITRAT
CCR INITIAL DX: DIET: 1/17 LY Clear 1.025 6 ++ - - - - - - - 0-2 0-2 0 0 ++
ANCILLARY:
ACUTE SUBDURAL
HEMATOMA MEDICATION:
JIMENEZ, JOSH-ZUA ESTRANO FRONTOTEMPOROPA
RIETAL RIGHT ACUTE
31/M 1/17 34 152 0.43 92 2.1 5.5 0 0.1 381
EPIDURAL MONITOR VS q2 and
DOB:12/8/88 HEMATOMA record
TEMPORAL RIGHT. Monitor input and
DOA: 1/17/2020 CONTUSSION output qshift CHEMISTRY CREA BUN AMY LIP NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
AS
HEMATOMA RIGHT 1/17 E 136 3.73
CC: VEHICULAR ACCIDENT FRONTAL PLAN:
SECONDARY TO Maintain MV setting
NOI: VA VEHICULAR Start oral hygiene:
ACCIDENT Chlorhexidine TID PT % INR CONTROL APTT CONTROL
DOI: 1/17/20 For stat ABG 1/17 20.40 26.20
TOI: 8AM
POI: ISABELA
Luis
NITRAT
CCR INITIAL DX: DIET: NPO 1/12/20 straw clear 1.010 6.0 - - - normal - + - - 2 0 0 0 1
MULTIPLE GUNSHOT ANCILLARY:

WOUND: POINT OF
ASIA, ROGELIO PESCADOR ENTRY 1. ANTERIOR MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
CHEST 2ND
46/M 1/12/20 17.4 137 0.40 82 8.3 5.5 3.7 0.5 300 92 31 339
INTERCOSTAL SPACE, ampicillin-sulbactam
MID CLAVICULAR 1.5g/IV
LINE RIGHT; POINT Omeprazole/ 40mg/IV
OF EXIT 1: NONE; ketorolac 30mg/IV
POINT OF ENTRY Tramadol 50mg/ml CHEMISTRY CREA BUN AMY LIPA NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
DOB: 2:LEFT CHEEK; POINT SE
OF EXIT 2: NONE; MONITOR VS q2 and 1/13/20 111 142.61 98.64
DOA: JAN 12 2020 POINT OF ENTRY 3: record 1/12/2020 140.10 3.90
LEFT DELTOID; POINT Monitor input and

CC: GUN SHOT WOUND OF EXIT; LEFT UPPER output qshift PT INR % Control PTT Control
BACK, POST AXILLARY

6th hospital day PLAN: 1/12/2020 11.40 19.70
LINE; POINT OF
Varma May remove IFC now
ENTRY 4; LEFT
MEDIAL FOREARM;
POINT OF EXIT 4;
NONE
NITRAT
IVF: PNSS 1Lx KVO E
CCR 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
MAXILLARY LINE PLAN:
For repeat CXR PA
Continue incentive
DOB:11/ 14/ 1994 spirometry CHEMISTRY CREA BUN AMY LIPASE NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
Daily CTT care

DOA: 12/ 26/ 2019 1/06/20 133.10 4.57
1/12/20 61.60 137 4.26

CC: stab wound
24TH hospital stay
1/12/20 12.40 31.60
bincey
IVF: PNSS 1L X 10 HRS NITRAT

DIET: DAT with SAP E
CCR INITIAL DX:
ANCILLARY:
PAET, REYNALDO JR SALVADOR MULTIPLE PHYSICAL
INJURY SEC. TO VA MEDICATION
32/M Ampicillin- Sulbactam
MINIMAL ACUTE 1.5 g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 07/20/1987 SUBDURAL 1/15/20 25.5 140 0.40 83.5 10.5 5.2 0.2 0.6 422 85 30 353
Mannitol 100cc IV q4
HEMATOMA, RIGHT Omeprazole 40 mg IV
DOA: 01/15/2020
TEMPORAL OD
CC: LOC TRAUMATIC Ketorolac 30mg IV PRN
SUBARACHNOID for pain q6
NOI: VA HEMORRHAGE CHEM CREA BUN AMY LIPA NA K CL MG CA ALBU GLOBU AST ALT TB TP A/ CEA
ISTRY SE MIN LIN G
PLAN:
1/15 138.40 4.01
TOI: 12 AM /20
Continue present
DOI: 1/15/20 Mangement
POI: BAGGAO
3rd HOSPITAL DAY 1/15/20 13.40 1.07 87.9 21.4
AISLES LEFT
IVF: PNSS 1L X 8 HRS
AL-L NITRAT
INITIAL DX: DIET: NPO UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
E
Leukocyte RBC WBC EPITH HYALI BACTERIA
AGUILLON, CHRISTIAN DAVE MULTIPLE PHYSICAL ANCILLARY:

CASTRO INJURY SEC. TO VA
MEDICATION:
20/M OPEN FRACTURE, Ampicillin- Sulbactam
LEFT LEG 1.5g q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
DOB: 07/17/20
Ketorolac 30mg IV q8 1/15/20 19.6 132 0.39 83.1 9.1 7.5 0.1 0.2 367 87 29 335
DOA: 01/14/20 PRN for pain

Omeprazole 40mg IV q24
CC: GROSS DEFORMITY ON LEFT Cefoxitin 1g IV q8
LEG Gentamycin 240mg IV x
7 days CHEMISTRY CREA BUN AMY LIPA NA K CL MG CA ALBUMIN GLOBULIN AST ALT TB TP A/G CEA
NOI: VA SE
PLAN: 1/15/20 140.40 3.43
TOI: 8:30PM GS/NSS cleared

may proceed with “E”
DOI: 1/14/20 debridement PT INR % Control PTT Control
Inform ortho service
POI: TUG. CITY 1/15/2020 14.80 1.18 74.10 25.20
nd
3 HOSPITAL DAY
TRAUMA FEMALE A
PATIENT DIAGNOSIS MEDICATIONS DIAGNOSTICS
NITRAT
IVF: PNSS 1L x12hours E
TFA INITIAL DX: DIET: DAT with SAP 1/102020

INJURY SECONDARY
AGLUGUB, FELICISIMO GARCIA TO VEHICULAR MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
ACCIDENT; BLUNT 1. Tramadol 50 1/06/20 12.3 123 0.39 75.4 13.8 10.3 0.2 0.3 241 87 28 319
72/M
CHEST TRAUMA, mg IV q8 1/10/20 14.2 125 0.38 87.5 6.1 6.2 0.0 0.2 275 86 28 330
MULTIPLE RIB 2. Celecoxib

FRACTURE 4TH-5TH 200mg cap
DOB: 03/24/47 RIBS, LEFT SPINAL BID prn for
CORD INJURY pain CHEMISTRY CREA BUN AMY LIPASE NA K UREA FAST GLU CHOLE TRIGLY HDL LDL ALT TB TP A/G CEA
DOA: 01/06/20 3. Salbu + iprat
neb q6 1/06/20 138 4.18 5.00
1/09/20 5.4 3.87 0.82 1.49 2.01

MONITOR VS q4 and
CC: VEHICULAR ACCIDENT record 1/10/20 137.20 4.08
Monitor input and PT % INR CONTROL APTT CONTROL
th
output q shift
11 HOSPITAL DAY
Bev PLAN:
For removal of CTT
continue IS
Continue Nebulization
q8
NITRAT
TM-B INITIAL DX: DIET: Soft Diet then add 1/10/2020
2 egg whites each meal

MULTIPLE STAB
WOUND 8TH ANCILLARY:
ARNEDO, SEVERINO GALARCE INTERCOSTALS CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
SPACE, RIGHT. LEFT MEDICATION: 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. Human Albumin, 1 Vial
POSTERIOR ARM, to run for 6hours q12
LEFT
MONITOR VS q2 and
record 1/09/20 3.63 142.61 98.64
DOB:07/26/1967 Monitor input and 1/12/2020 4.11
output qshift
1/14/2020 21 26.30 47 0.8
DOA: 0
CC: Stab wound Continue incentive
spirometry
Encourage ambulaltion
Jesserene Continue present
management
NITRAT
TF-A INITIAL DX: DIET: DAT with SAP

INJURY SECONDARY CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
CORTEZ, JOHANN MICHAEL TO VEHICULAR MEDICATION: 1/09/20 13.0 162 0.45 81.6 12.3 5.9 0.1 0.1 213 82 30 359
ACCIDENT, ACUTE 1. Vitamin B
38/M
SUBDURAL Complex tab
HEMATOMA, LEFT 1 tab OD
FRONTOTEMPOROPA 2. Ampicillin-
DOB:05/01/64 RIETAL AREA 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
3. Omeprazole 1/09/20 138.90 3.80
DOA: 01/09/20
40mg IV OD 1/14/20 129.90 3.89
4. Mannitol PT % INR CONTROL APTT CONTROL
100cc 10pNSS
CC: VA q6 with BP
prec
HISTORY: Start Ascorbic

Acid500/mg tab
NOI: VA (MOTORCYCLE)
Start Mannitol 100cc/IV
TOI: 12AM Start Incentive
spirometry
POI: BAGGAO, CAGAYAN
PLAN:
DOI: 11/09/20 Continue Medications
WOF DOB, desaturation
9th HOSPITAL DAY
luis
NITRAT
IVF: D5LR 1LX 12HOUR E
TF-A INITIAL DX: DIET: May have Soft Diet Yellow Clear 1.030 6 - Trace Trace - - + - - 16 21 10 1 96
ANCILLARY:
EVICERATED BOWEL
SECONDARY TO MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
BARRERO, JAYCEE ANUA STABWOUND LEFT 1/14 9.2 111 0.34 74 17 7.9 0.5 0.2 239
LOWER QUADRANT
26/M
Continue present
management
Daily wound care
DOB: Jun 13 1993 Encourage ambulation
CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL AST ALT TB TP A/G CEA
Maintain present diet,
DOA: 01/12/20 please refer prior to 1/12 84 140 4.29 37 49
discharge 1/14 4.12
CC: Stab wound
HISTORY:
NOI: Stab wound
TOI: 7AM
POI: MACUNACON, ISABELA
DOI: 1/12/2020
4th HOSPITAL DAY
NITRAT
IVF: PNSS 1 L X 12 HRS E
TF-A INITIAL DX: DIET: LOW SALT, LOW
FAT DIET
CAPINLAC, ROMAN BASA CONTUSION
HEMATOMA, RIGHT CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
58/M ANCILLARY:
FRONTOTEMPORAL 1/15/20 10.8 169 0.46 73 17 8.8 0.1 0.8 212 81 30 365
DOB: 11/20/1963 AREA SEC. TO FALL

MEDICATION
Ampicillin- Sulbactam
DOA: 01/15/2020
1.5 g IV q8
Mannitol 150 cc q4
CC: LOC CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
Ketorolac 30 mg q8 IV
NOI: FALL PRN for pain 1/15 133 3.24
1/16 13.30 5.04 1.37 1.29 3.12

TOI: 5PM PLAN: PT % INR CONTROL APTT CONTROL
Carry out IM notes 1/15/20 13.50 27.10
DOI: 1/12/20
Start celecoxib 200mg/
POI: ISABELA cap BID PRN
3rd HOSPITAL DAY
TRAUMA FEMALE B
IVF: PNSS 1L KVO 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 DY Hazy 1.010 7.5 - TRACE + - - - - 24 5 1 1

-
PNEUMOHEMOTHOR ANCILLARY:
AX SECONDARY TO
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
ANTERIOR CHEST 6TH 1. Celecoxib 1/9/2020 16.2 131 0.40 70 13.7 13.3 2.6 0.4 256 88 29 328
22/M
INTERCOSTAL SPACE 200mg/cap, 1 1/15/20 17.6 132 0.39 65.4 19.2 7.2 7.5 0.7 474 86 29 336
MIDCLAVICULAR LINE cap BID PRN

LEFT for pain
DOB:09/08/97 2. Salbutamol
neb q6 CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
DOA: 01/09/20 3. Ampicillin-
Sulbactam 1/07/20 134.30 4.16
1.5g IV q8 1/15/20 136.10 4.15

CC: STAB WOUND
PLAN:
Continue incentive
HISTORY: Continue present
medications
NOI: STAB WOUND
TOI: 11PM
POI: LASAM, CAGAYAN
DOI: 11/07/20
9th HOSPITAL DAY
POST OP DAY 9
bincey
IVF: PNSS 1Lx 8 hrs

TF-B INITIAL DX: DIET: NPO UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
E
JARA, JUDY JR SEATRIZ T/C BRAIN ABSCESS,

ANCILLARY:
RIGHT
34/M
FRONTOTEMPORAL
DOB: 04/29/1985 S/P E' CRANIECTOMY, MEDICATION CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
RIGHT EVACUATION Ceftriaxone 2g IV q12 1/14/20 9.7 159 0.46 71.9 19.6 7.2 1.1 0.2 322 85 30 348
DOA: 01/14/20 OF HEMATOMA FOR Vancomycin 1g IV q12
ACUTE EPIDURAL Ketorolac 30mg IV q8
CC: GENERALIZD BODY WEAKNESS PRN for pain
HEMATOMA,
TEMPORO-PARIETAL,
(+) HEADACHE RIGHT WITH PLAN: CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
DEPRESSED SKULL Pls insert IFC and NGT
(+) DIZZINESS FRACTURE , RIGHT Repeat ABG 1hour post 1/15/20 75.20 136.8 4.08 93
.6
FRONTOTEMPOROPA hooking to MV
(+) N/V RIETAL SEC. TO VA request for Crea, CBG, PT % INR CONTROL APTT CONTROL
NA, K 1/14/20 14.80 1.17 75.80 25.80
Start levophed drip at
10ugtts ESR: 24mm/hr
4th Hospital stay
IVF: PNSS 1L X 8 HRS UA COLOR TRANS Sp. Gr pH GLU CHON KETONE UROBILI BILI BLOOD
NITRAT
TF-B INITIAL DX: DIET: DAT
E
DANAO, PAULO MARTIN MULTIPLE PHYSICAL

INJURY SEC. TO ANCILLARY:
39/M MAULING CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
MEDICATION 1/14/20 10 148 0.43 73.2 19.7 5.8 1 0.3 185 84 29 342
DOB: 06/6/1980 CONTUSION Ampicillin-Sulbactam 1.5
HEMATOMA, RIGHT g IV q8
DOA: 01/14/2020
FRONTOTEMPOROPA Ketorolac 30mg IV PRN
RIETAL for pain
CC: SEVERE HEADACHE
Mannitol 150 cc IV then CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
decrease to 100cc q4
1/14/20 131.1 4.47
NOI: MAULING with BP precaution
1/18 93 130.80 3.95
TOI: 7PM PLAN: PT % INR CONTROL APTT CONTROL
Decrease mannitol to 1/14/20 12.70 97 1.02 25

DOI: 1/09/20 100cc q6
For repeat cranial CT
POI: AMULUNG scan
for repeat NA, K, Crea
4TH hospital day
ISOLATION
GS1
NITRAT
GS-1 INITIAL DX: DIET: Soft Diet E
Light
11/14/20 Clear 1.020 6.0 - - - normal - - - - 0 0 0 0 1
Yellow
TOMAS, VIRGILIO PILAR ACUTE APPENDICITIS ANCILLARY
MEDICATION
74/M Cefoxitin 1g IV q8 CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Metronidazole 500mg 1/14/20 18 125 0.36 93.4 4.5 1.8 0.2 0.1 273 90 31 346
DOB: 03/28/1945
IV q8
DOA: 01/14/20 Omeprazole 40 mg IV
OD
CC:RLQ PAIN
PLAN: CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
4th HOSPITAL DAY Continue medications
1/14/20 136.80 3.82
1/14/20 12.90 94.20 1.03 31.50
NITRAT
GS-1 INITIAL DX: DIET: SOFT E
LY Clear 1.015 7 - - - - - - - + 0-2 1-3 +
LACUBAN, LUZVIMINDA ACOM ACUTE APPENDICITIS ANCILLARY

MEDICATION
54/M CEFOXITIN 1G/IV CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Metronidazole 500mg/IV 1/16 15 114 0.36 66 23 5.3 5.2 0.3 278

DOB: 08/3.65
Omeprazole 40mg/IV
DOA: 01/16/2020
MONITOR: VS q4 and
CC: RUQ PAIN record
Monitor I&Oqshift and CHEMISTRY CREA BUN AMY LIPASE NA K CL FAS GLU CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
2nd HOSPITAL DAY record
1/16 142.30 3.71
PLAN:
D/C D5LR PT % INR CONTROL APTT CONTROL
WOF sever abdominal
pain
OVERFLOW
NITRAT
IVF: PLRS1L x 8HRS E
DIET: DAT 1/13 LY Hazy 1.030 6 - - - - - - - - 4 1
OF INITIAL DX:
ANCILLARY:
PAROTID MASS
MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
MACANAN, NOEL VINASOY 1. 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
DOB: DEC 21 1970 output qshift
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:
Refer to IM-ENDO
for comanagement PT % INR CONTROL APTT CONTROL
CC: NECK MASS once result of

Hba1c and UA is
available
HISTORY:
5th hospital day
luis
NITRAT
IVF: PLRS1L x KVO E
ROOM: OF INITIAL DX: DIET: DAT with SAP 1/13/2020 LY Clear 1.020 6 - - - - - - - +++ 9 57 12 521
INVASIVE DUCTAL ANCILLARY:

CARCINOMA RIGHT
GONONG, REDENTA ROMERO T3N2Mx? Of III A MEDICATION: CBC WBC Hgb Hct N L M E B Plt MCV MCH MCHC BTRh
Ketorolac 30mg IV q6 x
55/F 1/13/20 7.9 137 0.42 55.4 33.2 7.4 3.2 0.8 280 81 27 329
6 doses
Celecoxib 200mg/tab
BID x 3 days
DOB: July 23 1964 Tramadol 50mg/ IV q6 x
4 doses
CHEMISTRY CREA BUN AMY LIPAS NA K CL FAS CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
DOA: 1/13/2020 Ondansetron 4g/IV E GLU
1/13/2020 136.5 4.49
MONITOR VS q4 and
record
CC: HX of CA Monitor input and
output qshift
HISTORY: PLAN:
1/13/20 12.20 27
Start ascorbic acid

5th hospital day Start B complex
Encourage ambulation
varma Daily wound care
URO
NITRAT
IVF: D5LR X 8 HRS E
URO INITIAL DX: DIET: NPO 1/16/2020
Light
Cloudy 1.010 9 - - ++ - - - - - 0-1 2-4 - +++
yello
CASTILLO, EDIMAR CARMELO INDIRECT INGUINAL ANCILLARY:

HERNIA, LEFT MEDICATION
34/M INCARCERATED Ampicillin-Sulbactam 1.5
g IV q8
DOB: 04/17/85 1/16/2020 11 136 0.40 90 5.9 2.8 0.3 0.3 266
Ketorolac 30mg IV PRN

DOA: 01/16/2020
for pain
CC: SCROTAL MASS Omeprazole 40mg IV OD
CHEMISTRY CREA BUN AMY LIPAS NA K CL FAS CHOOLE TRIGLY HDL LDL ALT TB TP A/G CEA
E GLU
PLAN: 1/16/2020 135 4.53
for E mesh hemioplasty

WOF severe abdominal
pain, vomitting
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 1. Cefuroxime
150mg/IV
17/M
2. Ranitidine 1
amp CHEMISTRY CREA BUN AMY LIPA NA K CL M CA ALBUM GLOBULIN AST ALT TB TP A/G CEA
3. Dexamethaso SE G IN
1/06/20 70.60 139 3.41 92
DOB:12/15/2002 ne 4g/IV
4. 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
16th hospital stay PLAN:

NEURO MGH
jesserene
Awaiting MRI result
IVF: D5LRS 1L x8hrs
GS-3 INITIAL DX: DIET: Soft Diet 1/10/20 32 105 0.31 84.1 6.3 9.4 0 0.2 250 77 26 337
ANCILLARY:
NITRAT
E
MALLO VICTORIA MABBORANG CALCULOUS MEDICATION: 1/102020 Y Clear 1.020 6 - - - - - - - - 3 7 7 1 19
CHOLECYSTITIS 5. Cefuroxime
72/M
150mg/IV
6. Omeprazole
40mg/IV
DOB: 2/8/1947 7. Ketorolac
30mg/IV CHEMISTRY CREA ALP AMY LIPAS NA K C M CA ALBUMIN GLOBULIN AST ALT TB DB IB HBsAG Anti-HBs
E L G
DOA: 01/10/2020 8. KCL drip
1/10/20 120 48 40 12 3.3 23 15 43. 27.6 15.7 NR 110.7
9. Tramadol 7 2 40 0
50mg/IV 1/11/20 4.1
6
10. HNBB 1
CC: abdominal pain AMP/IV PT INR % Control PTT Control
MONITOR VS q4 and 1/10/20 14.20 38.40

7th hospital stay record
Monitor input and
output qshift
novi
PLAN:
Continue Medications

IVF: D5LRS 1L x8hrs
GS-3 INITIAL DX: DIET: DAT AND SAP 1/14 7.9 113 0.34 78 9.5 8.1 3.4 0.3 400 83 28 335
ANCILLARY:
NITRAT
E
ALLAG, GERARDO ACEBEDO ELECTROLYTE MEDICATION:
IMBALANCE 11. Human
69/M SECONDARY TP POOR albumin 1 vial
ORAL INTAKE, T/C 12. tramadol CHEMISTRY CREA LDH AMY LIPASE NA K CA MG CL ALB GLOBULIN A/G TP TB DB IB CEA Anti-HBs
INTRAABDOMINAL 50mg/IV PRN
DOB: 06/10/50 MASS 1/16 486
MONITOR VS q4 and 1/14 132 4.23

DOA: 01/9/2020 record 1/11 1.1
Monitor input and
1/10 27 22.70 1.2 50 1.51
output qshift
CC: ABDOMINAL MASS PLAN: PT INR % Control PTT Control
Give furosemide
40mg/IV
9th hospital stay hook to 02 nasal cannula
2-3LPM
DISCHARGES

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 18, 2020

1/11/20 13.20 1.06 90.4 34.3

DOI: 01/06/20 PLAN:

MEDRAZO, CHRIS KYLE OLIVAS PENTRATING INJURY ANCILLARY:

1ST hospital day 4. Tranexamic

ARBOLANTE, MICHEAL GAMATA MULTIPLE ANCILLARY:

CC: VEHICULAR ACCIDENT INJURY 30mg/IV

TOI: 6PM MONITOR VS q4 and 1/18 15.20 39.20

MONITOR VS q4 and 1/11/20 133 4.39

PLAN: PT % INR CONTROL APTT CONTROL

6th Hospital day

GALLARDO, NICK ALAGANO MULTIPLE PHYSICAL

2nd Hospital day

MULTIPLE PHYSICAL ANCILLARY:

ACUTE EPIDURAL ANCILLARY:

Daily wound care

decrease manitol to 75cc

ANCILLARY: S/D Nirpid ½

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

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

CORTEZ HEMATOMA, ANCILLARY:

PRN for pain

Monitor I & O qshift and 1/18 140 4.26

DOI: 1/18/20 150ccq6 +paracetamol

MULTIPLE PHYSICAL ANCILLARY:

3nd HOSPITAL DAY

MULTIPLE PHYSICAL ANCILLARY:

CC: VEHICULAR ACCIDENT

POI: SOLANA CAGAYAN

2nd hospital day

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

PT INR % Control PTT Control

1ST HOSPITAL DAY

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

cycles 1/18/20 136 3.49

TM-B INITIAL DX: IVF: D5LRS 1L X 8 HRS NITRAT

DOA: 01/18/2020 HEMATOMA, RIGHT Ketorolac 30mg/IV

1/18/20 15.50 40.10

TM-B INITIAL DX: IVF: D5LRS 1L X 8 HRS NITRAT

PT INR % Control PTT Control

POI: TUGUEGARAO CITY

1ST Hospital stay

NOI: FALL PLAN:

CRITICAL CARE ROOM

MULTIPLE PHYSICAL ANCILLARY:

VEHICULAR output qshift PT % INR CONTROL APTT CONTROL

POI: CLAVERIA, CAGAYAN

1ST HOSPITAL DAY

MULTIPLE GUNSHOT ANCILLARY:

LEFT DELTOID; POINT Monitor input and

BACK, POST AXILLARY

MULTIPLE STAB ANCILLARY:

Daily CTT care

1/12/20 61.60 137 4.26

IVF: PNSS 1L X 10 HRS NITRAT

AGUILLON, CHRISTIAN DAVE MULTIPLE PHYSICAL ANCILLARY:

DOA: 01/14/20 PRN for pain