MEDICINE DAILY CENSUS (11/12/2021-11/13/2021)

MEDICAL WARD
NAME AGE SEX ADMISSION SERVICE ADMITTING DIAGNOSIS WORKING DIAGNOSIS SUBJECTIVE/OBJECTIVE PLAN
303-1 CABALTERA, JOHN 22 M 11/08/2021 SADSAD T/C ACUTE CVA INFARCT T/C ACUTE CVA INFARCT 110/80, AFEBRILE; CEFTRI D5
MART VS. BLEED VS. SOL; COMPLICATED GCS 12, (-)FEVER SOFT, LSLF DIET;
UTI CT MASSIVE INFARCT VS D/C CBG MONITORING
SOL ( INITIAL) FF UP OFFICIAL CT
303-2 CARAAN, TEE JAY 28 M 11/04/2021 GMA HYPOVOLEMIC SHOCK HYPOVOLEMIC SHOCK CREA 7.9 (8.3) METRO, CEFTRI D6;
AGE WITH SEVERE AGE WITH SEVERE K 2.56 NAHCO3 DRIP;
DEHYDRATION AKI SEC DEHYDRATION AKI SEC; I 5100 RPT CREA
COVID NEGATIVE O 4000 KCL DRIP
FOR IJ CATHETER INSERTION;

EMPERADOR, JUAN 38 M 11/08/2021 LYRYX ACUTE CVD INFARCT ACUTE CVD INFARCT 118/87, AFEBRILE; CBG MONITORING, IG
CARLOS PROBABLY PROBABLY GCS 15; STARTED AT 10U OD;
CARDIOEMBOLIC; HCVD CARDIOEMBOLIC; HCVD (-) CHEST PAIN, (-) DOB FOR 2DED ON MON
CAD AF-CVR HFrEF B CAD AF-CVR HFrEF B WITH EPISODE OF SITAGLIPTIN
NYHA II; SUBSTANCE NYHA II; SUBSTANCE HYPOTENSION GLARGINE 10 UNITS
ABUSE ABUSE TRIMET BID
(METAMPHETAMINE) (METAMPHETAMINE) LIMIT OFI
TYPE 2 DM START IVABRADINE
HOLD LANOXIN, CARVEDILOL,
FURO, LOSARTAN,
PAMPLONA, 59 M 11/09/2021 SILVA ACS, NSTEMI ACS, NSTEMI 115/74, AFEBRILE; ACS REGIMEN;
EDGAR (-) CHEST PAIN PROGRESSION OF CARDIAC
(-)CP, (-)DOB, 02 SAT 99%, REHAB
RPT TROP I 0.35 ENOX D3 +1
304-1 FLORA, GILDA 52 F 11/6/2021 LAJARA NONHEALING WOUND NONHEALING WOUND 110/80, AFEBRILE; PIPTAZ, CLINDA D4;
REFERRED LEFT LOWER ABDOMINAL LEFT LOWER ABDOMINAL  PAIN ON WOUND SITE, CBG MONITORING
TO QUADRANT, T/C QUADRANT, T/C (-) ABD PAIN (-)FEVER, FOR DEBRIDEMENT
SURGERY CELLULITIS, T2DM, CAP- CELLULITIS, T2DM, CAP- (-)DOB, STABLE VS PENDING CP
MR, COVID SUSPECT MR, COVID SUSPECT FOR BT 1 UNIT PRBC
306-1 MERILLES, JOSE 71 M 11/07/2021 SADSAD T/C CAP MR, COVID T/C CAP MR, COVID 150/90, AFEBRILE; CEFTRI D3, AZITH D2;
SUSPECT, ELECTROLYTE NEGATIVE, COPD, (+) DOB; FOR ABG, CBG MONITORING;
IMBALANCE ELECTROLYTE (+)DESATURATION, O2 SAT DNR/DNI
IMBALANCE 90%, RTPCR (-) AMINOPHYLLINE DRIP,
HYDROCORT
BUDESONIDE NEB
D/C DEXA
306-2 MANSE, HILARION 59 M 11/10/2021 RAP UGIB, ANEMIA SEC. UGIB, ANEMIA SEC. HGB 47 SOFT DIET
NEPHROLITHIASIS (-) MELENA OMEPRAZOLE 40MG TIV Q12
RIGHT, POLYCYSTIC (-) ABDOMINAL PAIN REBAMIPIDE TID
KIDNEY DISEASE S/P BT 2/6 U PRBC CBG MONITORING
FOR BT 2/6
306-2 ASILO, JONATHAN 46 M 11/05/2021 SALANGO ACS, NSTEMI; CAP MR, ACS, NSTEMI; CAP,MR, 120/80, AFEBRILE; PIPTAZ D7+1
COVID NEGATIVE (-) DOB; LEVOX D2
(+) HEMATOMA, R UPPER CHEST UTZ, 2D ECHO
ARM REFERRAL TO PULMO
UTS SEPTATED, 1000CC ADVISED THOC (VATS)
309 MALABANAN, 59 M 11/05/2021 SALANGO CAP MR, PE RIGHT PROB CAP MR, PE RIGHT PROB 100/70, AFEBRILE; PLEURAL FLUID ANALYSIS
IRENEO PARAPNEUMONIC, PTB, PARAPNEUMONIC, PTB, (-) DOB; CEFTRI D/C
COVID 19 SUBCUTANEOUS CTT OUTPUT: 600CC METFORMIN 500 BID
COLON CA S/P EMPHYSEMA, COVID NO DOB, NO FEVER, CTT ATORVASTATIN 20
 COLOSTOMY NEGATIVE, COLON CA OUTPUT 50CC BLOODY
STAGE 1B P/ RPT CXRAY CLEARING OF
COLOSTOMY TYPE 2 DM, PE RIGHT
DYSLIPIDEMIA

ICU
NAME AGE SEX ADMISSION SERVICE ADMITTING DIAGNOSIS WORKING DIAGNOSIS SUBJECTIVE/OBJECTIVE PLAN

COVID ISO WARD

NAME AGE SEX ADMISSION SERVICE ADMITTING DIAGNOSIS WORKING DIAGNOSIS SUBJECTIVE/OBJECTIVE PLAN
B4 GARCIA, JOHN 30 M 11/08/2021 LYRYX ACUTE PANCREATITIS; ACUTE PANCREATITIS; 100/60, AFEBRILE; FF UP LABS;
COVID SUSPECT; COVID SUSPECT; (+)ABDOMINAL PAIN CBG MONITORING;
PNEUMONIA MODERATE; PNEUMONIA MODERATE; K 2.81 STILL NPO
PTB PTB MAINTAIN ON NPO,
BACTERIOLOGICALLY BACTERIOLOGICALLY K CORRECTION
CONFIRMED; DM TYPE 2 CONFIRMED; DM TYPE 2
B5 MANLANGIT, 68 M 11/09/2021 SILVA MASSIVE PLEURAL MASSIVE PLEURAL 120/90, AFEBRILE; CEFTR D1, AZITH D3;
GERARDO EFFUSION, L, PROBABLY EFFUSION, L, PROBABLY (-) DOB; FF UP LABS;
PARAPNEUMONIC VS PARAPNEUMONIC VS 96% 3NC FF UP GS REFERRAL
PTB; AKI 2° TO ACUTE PTB; AKI 2° TO ACUTE (+) DOB , O2 SAT 95, FEBUXOSTAT, SALB MDI,
ILLNESS; COVID ILLNESS; COVID PE 2000CC FOR CTT C/O SURG
SUSPECT SUSPECT
B6 PAMA, ANDRES 72 F 11/12/2021 SALANGO CVD INFARCT RMCA, CVD INFARCT RMCA, GCS 15 E4 V5 M6 FF UP OFFICIAL CRANIAL CT
HASCVD, CAP MR, COVID HASCVD, CAP MR, COVID COMFORTABLE CEFTRIAXONE
SUSPECT SUSPECT CXR PNEUMONIA AZITHROMYCIN
B7 FUENTES, VICENTE 59 M 11/12/2021 GMA HYPOGLYCEMIA SEC HYPOGLYCEMIA SEC GCS 15 CBG MONITORING PRE MEALS
OHA, TYPE 2 DM OHA, TYPE 2 DM CBG ELEVATED AND HS

COVID ISO TENT

NAME AGE SEX ADMISSION SERVICE ADMITTING DIAGNOSIS WORKING DIAGNOSIS SUBJECTIVE/OBJECTIVE PLAN
B1 SERNAL, LETICIA 54 F 11/08/2021 SADSAD HYPOGLYCEIA PROB HYPOGLYCEIA PROB COMFORTABLE DNI/DNR
DRUG-INDUCED VS. DRUG-INDUCED VS. CXR PN, O2 SAT 98 AZITHRO D3, CEFTRI D3, SOFT
POOR ORAL INTAKE R/O POOR ORAL INTAKE R/O CBG 228 DIET
CVA CVA TRANSFER TO MW
COVID SUSPECT, PTB COVID(-), PTB
B2 DEL ROSARIO, 66 M 11/07/2021 LAJARA ACS-NSTEMI, CAP-MR, ACS-NSTEMI, CAP-MR, 130/90, AFEBRILE; CEFTRI, AZITH D3;
IGNACIO PLEURAL EFFUSION PLEURAL EFFUSION O2 SAT 99% NAC;
RIGHT, COVID SUSPECT RIGHT, COVID SUSPECT COMFORTABLE TRANSFER TO MED WARD
BIL PE 130-150CC
B3 FERNANDEZ, 50 M 11/10/2021 SILVA CAP, MR WITH CAP, MR WITH 100/60, AFEBRILE; TO START PIPTAZ, AZITH;
JAMES CONSOLIDATION, L; CONSOLIDATION, L; (+) DEC BIPEDAL EDEMA FUROSEMIDE;
COVID SUSPECT; CKD 2° COVID SUSPECT; CKD 2° (-)DOB, , O2 SAT 98 FF UP LABS
TO DKD; TYPE 2 DM; TO DKD; TYPE 2 DM; NAHCO3 BID FOR 2D ECHO
MULTIPLE ELECTROLYTE MULTIPLE ELECTROLYTE MUPIROCIN CREAM TID
IMBALANCE IMBALANCE, DECUBITUS REFER TO SURG
ULCER

B4 CORTES, EMILY 47 F 11/12/2021 SALANGO CVD INFARCT VS BLEED CVD INFARCT VS BLEED NO HEADACHE NICARDEPINE DRIP
 BP 160-180 FOR PLAIN CRANIAL CT SCAN
GCS 15 E4 V5 M6
B5 SIPRADO, 43 M 11/05/2021 GMA HYPOVOLEMIC SHOCK HYPOVOLEMIC SHOCK 150/100, AFEBRILE; (-) DOB, METRO, CEFTRI D8;
ROLANDO AGE WITH SEVERE AGE WITH SEVERE (-) CHEST PAIN NAHCO3 DRIP;
DEHYDRATION AKI SEC DEHYDRATION AKI SEC; UO 150CC X 8HRSCREA WAB UTZ;
COVID NEGATIVE 13.4, ABG MET ACIDOSIS REFER BACK TO NEPHRO,
CREA 13.4 REFER TO GS FOR IJ
CATHETER INSERTION;
FOR TRANSFER TO MW

TRIAGE
NAME AGE SEX ADMISSION SERVICE ADMITTING DIAGNOSIS WORKING DIAGNOSIS SUBJECTIVE/OBJECTIVE PLAN
TRIAGE AMANTE, ANDREA 72 F 11/13/2021 SALANGO CVD INFARCT RMCA, CVD INFARCT RMCA, GCS 12 E4V2M6 FF UP OFFICIAL CRANIAL CT
HASCVD, T2 DM, COVID HASCVD, T2 DM, COVID SCAN
SUSPECT SUSPECT

REFERRAL
WARD NAME AGE SEX ADMISSION SERVICE ADMITTING DIAGNOSIS WORKING DIAGNOSIS SUBJECTIVE/OBJECTIVE PLAN
ISO ENT SEGARRA, 56 M 11/09/2021 SURGERY ABSCESS, LEG R ABSCESS, LEG R; TYPE 2 120/80, AFEBRILE CEFU D1;
RODEL DM STABLE CBG MONITORING, INSULIN
RAYMUNDO SLIDING SCALE;
FF UP LABS
MGT CONTINUED
OB WARD SAGUM, ANNA 21 F 11/10/2021 OB S/P D AND C, HPP S/P D AND C, HPP K 1.6 K CORRECTION
MARIE 3/5 ON ALL EXTREMTIES RPT K
12 LECG
IONIZED CA AND MG
301 PALINO, VICKY 39 F 10/29/2021 OB S/P CS, S/P S/P CS, S/P 110/80, AFEBRILE; ATTACH OFFICIAL ECHO
HYSTERECTOMY HYSTERECTOMY, VAP; (-) DOB (+) FLUID JP DRAIN FOR CYSTOGRAM
BAIAE ,T/C BLADDER CXR PNEUMONIA CT BT PT PTT, RPT
INJURY RESOLVING PERI FLUID ANALYSIS
308-1 GALERA, 36 F 11/23/2021 SURG NON HEALING WOUND NON HEALING WOUND INITIAL CBG 400MG/DL CBG MONITORING
CRISTALLI LEFT, T2 DM LEFT, T2 DM PENDING LABS
308-3 MANRILLA, 37 F 11/23/2021 SURG CELLULITIS LEG RIGHT, CELLULITIS LEG RIGHT, CBG MONITORING
JOCELYN PU 11-12 WKS AOG PU 11-12 WKS AOG PENDING LABS
APOLLO SALANGO MD