Landasan 1

10/21/24, 10:51 AM Clinical Abstract - RADISH
PGH Form No. P-310010 (Revised January 2008) [Last updated by: doc_cdachondo@radish.com (10-21-24 10:48 AM)]
CLINICAL ABSTRACT
Name of Hospital/Ambulatory Clinic: Case No.: 5346434

PHILIPPINE GENERAL HOSPITAL Admission: Date: Oct 16,
2024 Time: 02:14 AM
Accreditation No.: (PHIC) H91005030
Address of Hospital/Ambulatory Clinic: Barangay
TAFT AVENUE, ERMITA 670
Municipality/City Province Zip
MANILA NCR Code
1000
PATIENT'S CLINICAL RECORD
1. Patient Name 2. Age 43 y 3. Sex F
Last Name LANDASAN
First Name CHONALYN 4. No Assigned Consultant /
/
Middle Name PREMINTIL
*DOCTOR'S NAME [PRC No. _______]/ACHONDO, CARLOS JR. DAYUPAY
[PRC No. _______]/*DOCTOR'S NAME [PRC No. _______]
Printed Name and Signature of Admitting Officer
5. Admitting Diagnosis
ADE likely 1.) t/c SJS (<5%BSA) 2.) r/o DRESS from Mefenamic Acid, Amoxicillin, Paracetamol (Urticaria, Mucositis)
6. Chief Complaint
Pruritus
7. Reason for Admission

Pruritus
8. Brief History of Present Illness/OB History:

HPI:
Three weeks prior, patient had one episode of fever, no thermometer at home, associated with headache and generalized body weakness.
She self medicated with Mefenamic Acid (Advil), unrecalled frequency with resolution of fever and headache.
One week prior, she suddenly noted appearance of pruritic, erythematous papules beginning on the face, neck and upper extremities. She
sought consult at a local hospital where she was assessed as a case of Dengue Fever, sent home with Paracetamol explaining that her
platelet counts are within normal hence no reason for admission.
In the interim persistence of previously described lesions now extending to the trunk and lower extremities prompted consult at AMBU of
our institution, four days ago where she was assessed again as Dengue Fever and her rashes can be explained by the illness. She was sent
home with Paracetamol, Cetirizine, and Amoxicillin where she took with good compliance.
In the interim she noted mild resolution of the skin lesions however a day prior to consult the lesions recurred with more intense pruritus
and now affecting her oral mucosa preventing her to eat foods due to pain hence consult at our institution.
172.30.1.18/radish/cform/show_abstract/268054/306148/Admission 1/3
9. Physical Examination (Pertinent Findings per System)

General Survey Awake, alert, oriented
Vital Signs: BP: 140/80 HR: 82 RR: 18 Temperature: 36.6 Weight: NA kg Height: NA cm
HEENT: Anicteric sclera, pink palpebral conjunctiva, no distended neck vein, desquamating rashes on oral mucosa particularly both upper and
lower lips, unable to open mouth widely enough due to pain
Chest/Lungs: Symmetric chest expansion, clear breath sounds
CVS: Adynamic precordium, DHS, NRRR, no murmur
Abdomen: Soft, nontender, normoactive bowels, with extension of skin lesions to the abdomen and back
GU/IE: Grossly Female
Skin/Extremities: Full and equal pulses, generalized pruritic, nontender, erythamatous, papule and plaques skin lesions without desquamation
on bilateral Upper and Lower extremities, trunk, abdomen, back, buttock, mons pubis, labial folds (-) nikolsky sign
Neuro Examination: GCS 15
10. Course in the Wards:

[2024-10-16] PATIENT WAS SEEN AND EXAMINED, NOTED GENERALIZED PRURITUS, CONSENT SIGNED, PATIENT WAS ADMITTED TO
ER, STARTED ON SOFT DIET, DIAGNOSTICS ORDERED, REFERRED TO DERMA AND ALLERGY ; [2024-10-17] PATIENT WAS SEEN AND
EXAMINED, NOT IN APPARENT DISTRESS COMPLAINING OF LIP PAIN UPON TALKING AND OPENING MOUTH, WITH NOTED
DIFFICULTY IN EATING DUE TO PAIN NO FEBRILE EPISODES, NO COUGH, NO COLDS NO CHEST PAINS, NO DOB NO ABDOMINAL
PAINS, NO NAUSEA, NO VOMITING NO NEW SUBJECTIVE COMPLAINTS, NOTED INPUTS FROM DERMA AND ALLERGY, MEDICATIONS
GIVEN, STARTED ONTRIAMCINOLONE ACETONIDE 0.1% LOTION OVER RASH IN TRUNK AND EXTREMITIES CLOBETASOL
PROPIONATE 0.05% OINTMENT TO VULVAR ULCERS, PRESENT MANAGEMENT CONTINUED ; [2024-10-18] PATIENT WAS SEEN AND
EXAMINED, TRANS IN FROM ER TO WARD, NO FEBRILE EPISODES NO DYSPNEA, NO INCREASED WORK OF BREATHING ON ROOM
AIR NO DESATURATIONS ON ROOM AIR NO CHEST PAIN NO NAUSEA AND VOMITING STILL WITH OCCASIONAL PRURITUS FROM
SKIN LESIONS BUT WITH BETTER DISPOSITION TODAY AS COMPARED FROM ADMISSION VERBALIZED LESS PAIN ON LIP LESIONS,
PRESENT MANAGEMENT CONTINUED, MONITORED Q4, REFERRED ACCORDINGLY; [2024-10-19] PATIENT WAS SEEN AND EXAMINED,
COMFORTABLE IN BED VERBALIZED LESSER PRURITUS ALL OVER SKIN NO DESQUAMATION NOTED NO FEBRILE EPISODES NO
INCREASED WORK OF BREATHING ON ROOM AIR NO CHEST PAIN, STARTED ON METRONIDAZOLE + MICONAZOLE NITRATE
VAGINAL SUPPOSITORY, INSERT 1 VAGINAL SUPPOSITORY TWICE A DAY FOR 7 DAYS, PRESENT MANAGEMENT CONTINUED,
MONITORED Q4, REFERRED ACCORDINGLY; [2024-10-20] PATIENT WAS SEEN AND EXAMINED, NO NEW RASH, NO BLISTERING
LESIONS IMPROVEMENT OF RASH IN BILATERAL LOWER EXTREMITIES NO FURTHER SLOUGHING OF LIPS NO FEVER NO OCULAR
PAIN, PRURITUS OR SENSATION OF DRY EYES, STARTED ON HYDROCORTISONE 1% CREAM ON FACIAL LESIONS, PRESENT
MANAGEMENT CONTINUED, MONITORED Q4, REFERRED ACCORDINGLY; [2024-10-21] SEEN AND EXAMINED TODAY NO NEW
PRURITIC LESIONS NO NEW RASHES NOTED NO DYSPNEA ON ROOM AIR NO FEBRILE EPISODES NO CHEST PAIN FOR HOME TODAY
ONCE CLEARED BY ALL CO MANAGING SERVICES, DISCHARGE PLANS AND MEDICATIONS EXPLAINED, REFERRED ACCORDINGLY;
11. Pertinent Laboratory and Pertinent Diagnostic Findings: (CBC, Urinalysis, Fecalysis, Xray, Biopsy, etc)
CBG; ; 10/21 139; ; 10/20 144 171; ; ; ; IO; ; 10/20 1560/1505; ; 10/19 700/290 (+410); ; ; ; Recent Labs:; ; ; ; CBC; ; 10/19 Hgb 121
Hct 36 WBC 12 (77/15/8/0) PC 463; ; 10/16 Hgb 95 HCt 30 WBC 9.7 (84/14/2/0/0) PC 629 normo, normo, low MCHC; ; ; ; Coags:; ;
10/17 PT 11.70 INR 1.00 APTT 27.7; ; ; ; CHEM; ; 10/16 Mg 0.82; ; 10/16 Na 138 K 4.2 TB 13 DB 8.4 IB 4.6 Alb 40 AST 27 ALT 33 BUN
3.6 Crea 59 (eGFR 111) Ca 2.18; ; ; ; Micro; ; Blood CS M229 AB NG5D
12. Surgical Operation/s - Anesthesia (with Date and Time)
No procedures on record.
Printed Name and Signature of Surgeon
Printed Name and Signature of Anesthesiologist
13. Discharge:
a. Date: NA b. Time NA
c. Final Diagnosis:
ADR to ibuprofen (SJS, BSA 2%); ; Adverse reaction to chicken and egg; ; Anemia likely from acute illness r/o nutritional; ;
Thrombocytosis, likely reactive from acute inflammation
d. Condition on Discharge: Improved
e. Signature of Attending Physician: No Assigned Consultant / /
*DOCTOR'S NAME [PRC No. _______]/ACHONDO, CARLOS JR. DAYUPAY [PRC No. _______]/*DOCTOR'S NAME [PRC No. _______]
(Note: DOCUMENT IS NOT VALID WITHOUT PHYSICIAN'S SIGNATURE)
14. Signature of Right Thumbmark of Patient or his/her Representative:
Printed Name & Signature of Patient or his/her Representative:
Right Thumbmark Printed Name and Signature of Witness to

(In case patient and representative could not write.) Thumbmark

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10/21/24, 10:51 AM Clinical Abstract - RADISH

Name of Hospital/Ambulatory Clinic: Case No.: 5346434

7. Reason for Admission

8. Brief History of Present Illness/OB History:

9. Physical Examination (Pertinent Findings per System)

CVS: Adynamic precordium, DHS, NRRR, no murmur

GU/IE: Grossly Female

10. Course in the Wards:

Printed Name and Signature of Surgeon

Printed Name and Signature of Anesthesiologist

d. Condition on Discharge: Improved

e. Signature of Attending Physician: No Assigned Consultant / /

Printed Name & Signature of Patient or his/her Representative:

Right Thumbmark Printed Name and Signature of Witness to

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