6/23/2021 OPD Clinical Abstract - RADISH

PGH Form No. P-310010 (Revised January 2008) [Last updated by: doc_mcaraan@radish.com (06-23-21 09:53 AM)]

CLINICAL ABSTRACT

Name of Hospital/Ambulatory Clinic: Case No.: 4565701

PHILIPPINE GENERAL HOSPITAL Admission: Date: Jun 23, 2021 Time: NA
Accreditation No.: (PHIC) H91005030
Address of Hospital/Ambulatory Clinic: Barangay
TAFT AVENUE, ERMITA 670
Municipality/City Province Zip Code
MANILA NCR 1000

PATIENT'S CLINICAL RECORD

1. Patient Name 2. Age 19 y 3. Sex F
Last Name SANTELICES
First Name JEPT ASHLEY 4. Attending Physician(s) Signature:

Middle Name DEL ROSARIO

Caraan, Melissa Nadine [Psych]
PRC License Number: 135389
5. Admitting Diagnosis
Persistent Depressive Disorder, currently in major depressive episode

6. Chief Complaint
Follow-up

7. Reason for Admission

Not admitted

8. Brief History of Present Illness/OB History:

3-year history of consult with Psychiatry following an attempted suicide by drug overdose

Currently being managed with the following:

Fluoxetine 20mg 2 capsules
Olanzapine 5mg 1/2 tablet
Propranolol 10mg 1 tablet

9. Physical Examination (Pertinent Findings per System)

General Survey Awake, alert
Vital Signs: BP: HR: RR: Temperature:
HEENT:

Chest/Lungs:

CVS:

Abdomen:

GU/IE:

Skin/Extremities:

Neuro Examination: MSE: Depressed mood, no suicidal ideations

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6/23/2021 OPD Clinical Abstract - RADISH

10. Course in the Wards:

11. Pertinent Laboratory and Pertinent Diagnostic Findings: (CBC, Urinalysis, Fecalysis, Xray, Biopsy, etc)
None

12. Surgical Operation/s - Anesthesia (with Date and Time)

None

Printed Name and Signature of Surgeon

Printed Name and Signature of Anesthesiologist

13. Discharge:
a. Date: NA b. Time NA
c. Final Diagnosis:
Persistent Depressive Disorder, currently in major depressive episode

d. Condition on Discharge: Stable

e. Signature of Attending Physician:

Caraan, Melissa Nadine [Psych]

PRC License Number: 135389
(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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