PHILIPPINE GENERAL HOSPITAL REQUEST FORM

The National University Hospital X-ray/Ultrasound

University of the Philippines Manila Contact number 5548400
DEPARTMENT OF RADIOLOGY Local numbers
Taft Avenue,Manila *Pay 3115 (during office hours)
3104/3113 (after office hours)
"PHIC Accredited Healthcare Provider" *Service 3105 (during office hours)
ISO 9001:2008 Certified 3104/3113 (after office hours)

PATIENT INFORMATION Date: Sep 01, 2021

Patient Name: MALAPAD, FILIPINA LORZANO Case No.: 4762989
Age/Sex: 46 y / F Birthday: 1975-01-20 X-RAY/ULTRASOUND
Patient's Address: File No.:
Patient's Contact No.: Ward/Clinic: OBGYN General Service Bed No.:
Contact/Local No.:

DESIRED EXAMINATION (Please specify examination/parts to be examined.):

- [XRAY]Chest (PA),
Abdominopelvic mass, probably benign Pelvic Endometriosis with right endometriotic cyst (+) S/P EL, bilateral oophorocystectomy x benign cyst (2009, Ospital ng Muntinlupa) (+) S/P EL, Enterolysis, (Sept 2020, Ospital ng Muntinlupa) S/P CSTU x dysfunctional labor (G1, 2004,
Ospital ng Muntinlupa) Obese Class I G1P1(1001)
-
COMPLETE CLINICAL IMPRESSION
Abdominopelvic mass, probably benign Pelvic Endometriosis with right endometriotic cyst (+) S/P EL, bilateral oophorocystectomy x benign cyst (2009, Ospital ng Muntinlupa) (+) S/P EL, Enterolysis, (Sept 2020, Ospital ng Muntinlupa) S/P
CSTU x dysfunctional labor (G1, 2004, Ospital ng Muntinlupa) Obese Class I G1P1(1001)

REQUESTING PHYSICIAN: PHYSICIAN'S CONTACT NO./LOCAL NO.

ORDER DATE: Sep 01, 2021 TIME: 03:29 PM

Villafuerte-Ong, Maezel (doc_mtvillafuerte@radish.com)
Please do not write below this line. For radiology staff use only.
APPROVAL FOR SCHEDULING: Evaluated/Approved By:

Regular Scheduling

Signature over printed name

Emergency

Date: Time:
FEES Examination/Study/ies MSS Classification - None. TOTAL:
Waived
PF/RF Senior Citizen PWD
PGH/UP/UPM employee, others
Others if any:

SCHEDULE OF EXAMINATION DATE OF EXAMINATION

Date: Time: Time of Arrival:

Scheduled by: Received by:

Signature over printed name Signature over printed name

Date & Time Date & Time

Provisional/Official Reading : (PLEASE DO NOT INSERT THIS INSIDE CHART.) This is not the official Radiologic Report Form.

Radiologic Technologist/Quality Control (Xray) Radiologist(s): Encoder:

Signature over printed name/Signature over printed name Signature over printed name Signature over printed name
Date and Time Date and Time Date and Time
PHILIPPINE GENERAL HOSPITAL REQUEST FORM
The National University Hospital X-ray/Ultrasound
University of the Philippines Manila Contact number 5548400
DEPARTMENT OF RADIOLOGY Local numbers
Taft Avenue,Manila *Pay 3115 (during office hours)
3104/3113 (after office hours)
"PHIC Accredited Healthcare Provider" *Service 3105 (during office hours)
ISO 9001:2008 Certified 3104/3113 (after office hours)

PATIENT INFORMATION Date: Sep 01, 2021

Patient Name: MALAPAD, FILIPINA LORZANO Case No.: 4762989
Age/Sex: 46 y / F Birthday: 1975-01-20 X-RAY/ULTRASOUND
Patient's Address: File No.:
Patient's Contact No.: Ward/Clinic: OBGYN General Service Bed No.:
Contact/Local No.:

DESIRED EXAMINATION (Please specify examination/parts to be examined.):

- [OBGYN] Transvaginal ultrasound, (C/O OB sonologist please)
Abdominopelvic mass, probably benign Pelvic Endometriosis with right endometriotic cyst (+) S/P EL, bilateral oophorocystectomy x benign cyst (2009, Ospital ng Muntinlupa) (+) S/P EL, Enterolysis, (Sept 2020, Ospital ng Muntinlupa) S/P CSTU x dysfunctional labor (G1, 2004,
Ospital ng Muntinlupa) Obese Class I G1P1(1001)
-
COMPLETE CLINICAL IMPRESSION
Abdominopelvic mass, probably benign Pelvic Endometriosis with right endometriotic cyst (+) S/P EL, bilateral oophorocystectomy x benign cyst (2009, Ospital ng Muntinlupa) (+) S/P EL, Enterolysis, (Sept 2020, Ospital ng Muntinlupa) S/P
CSTU x dysfunctional labor (G1, 2004, Ospital ng Muntinlupa) Obese Class I G1P1(1001)

REQUESTING PHYSICIAN: PHYSICIAN'S CONTACT NO./LOCAL NO.

ORDER DATE: Sep 01, 2021 TIME: 03:29 PM

Villafuerte-Ong, Maezel (doc_mtvillafuerte@radish.com)
Please do not write below this line. For radiology staff use only.
APPROVAL FOR SCHEDULING: Evaluated/Approved By:

Regular Scheduling

Signature over printed name

Emergency

Date: Time:
FEES Examination/Study/ies MSS Classification - None. TOTAL:
Waived
PF/RF Senior Citizen PWD
PGH/UP/UPM employee, others
Others if any:

SCHEDULE OF EXAMINATION DATE OF EXAMINATION

Date: Time: Time of Arrival:

Scheduled by: Received by:

Signature over printed name Signature over printed name

Date & Time Date & Time

Provisional/Official Reading : (PLEASE DO NOT INSERT THIS INSIDE CHART.) This is not the official Radiologic Report Form.

Radiologic Technologist/Quality Control (Xray) Radiologist(s): Encoder:

Signature over printed name/Signature over printed name Signature over printed name Signature over printed name
Date and Time Date and Time Date and Time
PHILIPPINE GENERAL HOSPITAL REQUEST FORM
The National University Hospital CT Scan
University of the Philippines Manila Contact number 5548400
Department of Radiology Local numbers
CT-MRI Section Taft Avenue,Manila *Pay 3115 (during office hours)
3104/3120 (after office hours)
"PHIC Accredited Healthcare Provider" *Service 3118 (during office hours)
ISO 9001:2008 Certified 3104/3120 (after office hours)

PATIENT INFORMATION Date: Sep 01, 2021

Patient Name: MALAPAD, FILIPINA LORZANO Case No.: 4762989
Age/Sex: 46 y / F Weight (kg): Birthday: 1975-01-20 CT SCAN File No.:
Patient's Address: Ward/Clinic: OBGYN General Service Bed No.:
Patient's Contact No.: Contact/Local No.:

DESIRED EXAMINATION (Please specify examination/parts to be examined.):

- [CT]Whole Abdomen Double/Triple- Contrast-enhanced ,
Pertinent Clinical Information: 46/G1P1(1001) CC: Ovarian cyst PAST MEDICAL HISTORY (-) HTN, DM, PTB, BA (+) S/P EL, bilateral cystectomy x benign cyst (2009, Ospital ng Muntinlupa) (+) S/P EL, Enterolysis, (Sept 2020, Ospital ng Muntinlupa) no DM, no allergies, not
pregnant, no stoma Transvaginal/Transabdominal Ultrasound (10/30/20, Comia/Abecia) IMPRESSION: ABDOMINOPELVIC MASS CONSIDER PSEUDOCYST FORMATION NORMAL-SIZED UTERUS WITH POSTERIOR ADENOMYA THIN ENDOMETRIUM RIGHT OVARIAN CYST
CONSIDER ENDOMETRIOTIC CYST NORMAL LEFT OVARY WITH PARATUBAL CYST PELVIC SIDE WALL AND CUL DE SAC ADHESIONS Abdominal CT Scan with IV contrast (Oct 7, 2020, ospital ng Muntinlupa) - Abdominopelvic mass: Large lobulated, predominantly cystic mass with
few internal enhancing septations and small solid mural nodularities more on the left measuring 24.6x16.7x14.3cm - Minimal Pneumoperitoneum, spinal canal air pockets and anterior abdominal wall defect likely postprocedural in nature - suspicious lower uterine
segment/cervical hypodense nodule -minimal bilateral pleural effusion -subsegmental pulmonary atelectasis - mild degenerative osseous changes Abdominopelvic mass, probably benign Pelvic Endometriosis with right endometriotic cyst (+) S/P EL, bilateral oophorocystectomy
x benign cyst (2009, Ospital ng Muntinlupa) (+) S/P EL, Enterolysis, (Sept 2020, Ospital ng Muntinlupa) S/P CSTU x dysfunctional labor (G1, 2004, Ospital ng Muntinlupa) Obese Class I G1P1(1001) eGFR: For extraction Requesting Physician: Dr. Ong
-
COMPLETE CLINICAL IMPRESSION
Abdominopelvic mass, probably benign Pelvic Endometriosis with right endometriotic cyst (+) S/P EL, bilateral oophorocystectomy x benign cyst (2009, Ospital ng Muntinlupa) (+) S/P EL, Enterolysis, (Sept 2020, Ospital ng Muntinlupa) S/P
CSTU x dysfunctional labor (G1, 2004, Ospital ng Muntinlupa) Obese Class I G1P1(1001)
INDICATION FOR THE STUDY: Please give a description of the disease and the reason for this examination. Include updated history and physical examination or attach an updated clinical abstract to this request. You may use the back of this
form if necessary.

HISTORY OF PREVIOUS IMAGING EXAMINATION (xray, CT Scan, MRI or other imaging studies related to the disease process)
No Yes Type of Study: done in PGH Date: File No.:
done in another institution
PLEASE CHECK IF WITH: NGT Colostomy/Stoma ETT/Tracheostomy/O2 Others
POSSIBLY PREGNANT? No Yes
IF INTRAVENOUS CONTRAST IS TO BE USED
* History of allergies / asthma/ adverse reaction to IV CREATININE: Date taken:
No Yes Specify: GFR: ___ /Please secure renaal clearance if elevated
Diabetic patient taking Metformin
No Yes Date of last intake:
REQUESTING PHYSICIAN: PHYSICIAN'S CONTACT NO./LOCAL NO.

ORDER DATE: Sep 01, 2021 TIME: 03:29 PM

Villafuerte-Ong, Maezel (doc_mtvillafuerte@radish.com)
Please do not write below this line. For radiology staff use only.
APPROVAL FOR SCHEDULING: Evaluated/Approved By:

Regular Scheduling

Signature over printed name

Emergency

Date: Time:
FEES Examination/Study/ies MSS Classification - None. TOTAL:
Waived
PF/RF Senior Citizen PWD
PGH/UP/UPM employee, others
Others if any:
SCHEDULE OF EXAMINATION DATE OF EXAMINATION
Date: Time: Time of Arrival:
Scheduled by: Received by:
Signature over printed name
Date & Time Signature over printed name
Date & Time
Informed consent? Yes (Pleaase attach to request)
Name of IV contrast given: Time given: Batch No.: Volume (cc):
With adverse reaction to contrast during the examination?
No Yes
Management done:
Radiologic Technologist/Quality Control (Xray) Radiologist(s): Encoder:

Signature over printed name/Signature over printed name Signature over printed name Signature over printed name
Date and Time Date and Time Date and Time