SDS Medical Center, Inc.

Katipunan Extension cor. Pio del Pilar, Concepcion 2,

Marikina City
Phone Nos. 933.7078/948.5186
SDS Medical Center, Inc.
Katipunan Extension Cor. Pio Del Pilar
Concepcion 2, Marikina City
Tel No. 9331405

Name of Patient:
Date of Birth:
Case Number:
Attending Physician:

Acosta, Girardo
May 27, 1980
019109
Dr. Lazatin

CLINICAL ABSTRACT
Date of Admission:

August 10, 2015

Final diagnosis:

CAP MR

Chief Complaint:

Cough

Date of Discharge:

August 12, 2015

History of Present Illness:

Patient has 3 day history of cough and colds with sore throat. There was no associated fever, difficulty of
breathing, shortness of breath and chest pain. No medications were given. Persistence of symptoms
prompted consult.
Course in the wards:
Patient was admitted under the service of Dr. Lazatin. Consent secured. Vital signs were taken.
Laboratories were done. Patient was started on Cefuroxime, Combivent, Neozep, Paracetamol and
Fluimucil. After improvement, patient was cleared for discharge and may go home.
Home medications:
Follow up:

Cefuroxime 500mg tab 1 tab BID x 5 days

Fluimucil 200mg tab 1 tab TID x 5 days

As advised

Dr. Lazatin/Dr. Elaine Rochelle Talusan

Attending Physician/Resident-on-duty
Lic. No. 126032