SAMPLE REFERRAL TEXTS
[VIBER GC]
Good afternoon po, doctors
This will be the Viber GC for patient
WONG, AMANTE
77/M
SH 820
Managed as PULMONARY SQUAMOUS CELL
CARCINOMA ON RADIATION THERAPY;
HYPERTENSION; PAROXYSMAL AF;
CHRONIC ISCHEMIC HEART DISEASE;
HYPOKALEMIA
Dr. M. Cacanindin
Dr. X. Manalo (Jt)
Patient just arrived at his room
To be hooked to BIPAP
Thank you po docs
[PM DUTY - MORNING UPDATE]
With assessment and plan if needed
Good morning po doctors, this is PGI Manzano
one of the interns in charge here at SLU SHMC
8th floor, respectfully updating on patient
Floresca
S: Patient had a total of 5 bowel movements
since yesterday, semi solid in consistency, dark
green in color, non mucoid, non bloody. There
was associated diffuse abdominal pain and
discomfort, temporarily relieved with passing
stool. No nausea, vomiting, dysuria, dizziness,
DOB. Patient is able to tolerate oral food intake.
LFE: 4pm yesterday relieved with PCT
O:
BP: 100-110/60-70 (110/70)
PR: 70-86 (75)
RR: 16-18 (18)
T: 36.4-38 (36.4)
SPO2: 95-98% (97%@RA)
I&O (16 hrs): 4000 vs 2700
Awake, conversant, not in cardiopulmonary
distress
No pallor, jaundice, or cyanosis, warm to touch
with good skin turgor
Anicteric sclerae, pink palpebral conjunctivae,
moist lips and buccal mucosa, no CLAD,
non-distended neck veins, still with hair loss
Symmetrical chest wall expansion with fine
crackles, no wheezes
Adynamic precordium, no heaves, no thrills,
normal rate and regular rhythm
Flabby, non-distended, hyperactive bowel
sounds, tympanitic, non tender
No gross deformities, FEPP, CRT <2s, no
bipedal edema
ROM:
IVF: PNSS 1L x 80 cc/ hour
Diet: No fresh fruits and vegetable
#Febrile neutropenia; CAP-MR
Piperacillin- tazobactam (Vigocid) 4.5 g IV q6 -
D3 to be completed today at 12 pm
Levopront 15 ml TID
Zykast 1 tab ODHS
Paracetamol 500 mg, 1 tab q4 PRN for fever
#Back pain
Lagaflex 1 tab OD at HS PRN for back pain
Nuropat 1 tab OD (pts stock)
[JOINT MANAGEMENT] [JOINT MANAGEMENT - NEWLY ADMITTED]
Informing Consultant For Consultants who prefer text referrals
Good afternoon po Doc Will send the History and PE na lang po muna
This is PGI Manzano, one of the interns in of the Patient Doc
charge here at SLU SHMC 8th floor
TOKING, Marlyn
Respectfully referring patient David, Paulita 54/F
Hepatocellular Carcinoma Few hours prior
Ascites secondary to Liver Cirrhosis with The patient was just finished eating dinner at
Probable Spontaneous Bacterial Peritonitis their home when she experienced sudden
Hypertension severe headache, 9-10/10 in severity,
Type 2 Diabetes Mellitus originating from the right frontoparietal area,
Hypovolemic Hyponatremia radiating to the right occipital area and to the
nape, unrelieved with Paracetamol (Biogesic).
Referred to you (from Dr. Antonio) for Joint No associated Loss of Consciousness, Loss of
Management Balance, Blurring of Vision, Weakness,
Dizziness, Photophobia, Tinnitus, or Slurring of
Should I call for the referral po doc or should I Speech.
send instead the pertinent information? There was no prior head trauma or injury.
Patient had 2 episodes of vomiting of previously
Thank you po doc! ingested food, non projectile, non billous.
Patient consulted a rural health office, but was
only given Diclofenac 1 amp IM and was
monitored for High Blood pressure. Px was
then referred to this institution hence
admission.
PMH:
History of pre diabetes but was managed with
lifestyle modification
No other comorbids
No allergies
No previous surgeries
No maintenance meds
FH:
No family history of Cerebrovascular Disease
(+) Cardiac problem - Maternal side
SEH:
Non smoker, non alcoholic beverage drinker
PE:
GS: Awake, conversant, conscious
VS:
BP: 140/80 mmHg
PR: 61 bpm
RR: 16 cpm
T: 36.5 C
SpO2: 96% RA
Skin: (-) jaundice, (-) pallor, (-) cyanosis, warm
to touch with good skin turgor
HEENT: Anicteric sclerae, pink palpebral
conjunctiva, no TPC, no palpable cervical
Algesia 1 cap BID prn for pain
#Elevated liver enzyme
Godex DS 1 cap TID
Sending the latest labs po docs
Total Bilirubin: 0.98 mg/dL
CBC (09/19/23 vs 09/17/23)
ERYTHROCYTES: 2.9 L (2.9)
HEMOGLOBIN: 104 L (104)
HEMATOCRIT: 0.29 L (0.29)
MCV: 99.0 (99.7)
MCH: 36.1 H (35.5)
MCHC: 365 (356)
NORMOCYTIC, NORMOCHROMIC
WBC: 6.1 (2.9)
NEUTROPHILS: 67.6 H (42)
LYMPHOCYTES: 19.7 L (47)
MONOCYTES: 11.8 H (11)
EOSINOPHILS: 0.7 L (0)
BASOPHILS: 0.2 (0)
PLATELET COUNT: 125 L (230)
lymphadenopathies
C/L: SCWE, CEBS, no wheeze, no crackles
Heart: NRRR, no murmurs
Abd: Flabby, non distended, tympanitic, NABS,
no tenderness on palpation
Ext: FEPP, no edema, CRT <2 secs
Neuro:
Oriented to 3 spheres
(-) dysmetria, (-) dysdiadochokinesia
CN I: Able to smell the scent of coffee
CN II: PERRLA
CN III, IV, VI: EOMs intact
CN V: Able to clench jaw, able to identify fine
touch on both cheeks
CN VII: No facial asymmetry on raising
eyebrows, grinning, or speaking
CN VIII: Gross hearing intact
CN IX and X: Able to swallow, uvula at midline
CN XI: Able to move head side to side against
resistance
CN XII: Tongue at midline, no fasciculations
Sensory: 100% at all extremities
Motor: 5/5 on all extremities
Reflexes: 2+ on all extremities

A: t/c Antibiotic-associated Diarrhea P:

Awaiting CT Scan Result (official reading)
P: Increase oral fluid intake
Suggest to apply warm compress over the Diagnostics done
stomach, with burn precautions RBC: 5.2
Suggest to start Erceflora 1 tube TID Hgb: 157
Hct: 0.44
Thank you po docs! MCV: 83.7
MCH: 30.0
MCHC: 358
Morphology: Normocytic, normochromic
Plt ct: 276
WBC: 9.5
Neutro: 78.5 H
Lympho: 16.8 L
Eosino: 0.1 L
Mono: 4.4
Baso: 0.2
NRBC#: 0.0

Crea: 0.57 mg/dL

egfr: 108 mL/min/1.73

Na: 135.70 mmol/L

APTT: 34.30 secs

PTPA
Patient’s Plasma: 12.15 secs
Control Plasma: 13.4 secs
PT Activity: 100.5 %
INR: 1.01
Thank you po doc!
[JOINT MANAGEMENT] [REFERRAL - NEW PROBLEM] [REFERRAL - NEW PROBLEM SAMPLE #2] [6th - CCU/Pallia - OPD CHEMO]
Patient na matagal ng admitted
Good afternoon docs Good morning po doc [CHEMO-OPD]
Good afternoon po doc, respectfully relaying Respectfully referring patient Alquiza Referring Patient Chaokas Good morning po docs, relaying
patient s/p ERCP with stenting s/p re ExLap repair of Patient Senting, Rosemarie, 59/F, Breast
DAVID, Paulita biliary fistula S: (+) Upper Back pain, 4/10 in severity, Cancer Stage 2A, under Dr. Flores
68/F aggravated when moving (side to side) or lying for 6th Cycle of Chemotherapy
Managed as a case of Hepatocellular CC: Cough in supine position, sharp in character, radiating
Carcinoma; Ascites secondary to Liver to the nape area, relieved when steadying the Initial VS:
Cirrhosis with Probable Spontaneous Bacterial S: Patient had gradual onset of productive position, (-) headache, (-) dizziness, (-) blurring BP: 130/90
Peritonitis; Hypertension; Type 2 Diabetes cough starting this morning, with watery clear of vision, (-) weakness, (-) nausea, (-) DOB, (-) PR: 79
Mellitus; Hypovolemic Hyponatremia sputum. There was associated runny nose, with Cough RR: 16
clear watery discharge, no associated T: 36.7
Currently on Hospital Day 4 congestion, headache, or sneezing episodes. O: SpO2: 97% at RA
S: According to the watcher, the patient Nasal discharge gradually diminished in the Awake, conversant, oriented
appeared to be better than yesterday. Patient afternoon, however, productive cough persisted VS Ht: 165.5
has no complaints of difficulty breathing, chest now with associated clear, thick, sputum, BP: 130/70 mmHg Wt: 70 kg
tightness, abdominal pain, dizziness, nausea. coughing relieved upon expectorating. No PR: 83 bpm BMI: 25.6
There was noted improvement in appetite but associated febrile episodes, nausea, vomiting, RR: 19 cpm BSA: 1.79
still decreased. dyspnea, shortness of breath, palpitations, T: 36.6 C
chest heaviness/pain. SpO2: 93% RA -> 95% at RA with DBE CBCP (seen by Doc Flores)
O: C/L: SCWE, no lagging, no wheeze, no RBC: 3.44
Anthropometrics O: crackles Hgb: 103 L
Ht: 149 cm GS: Conscious, ambulatory, conversant, alert Musculoskeletal: (-) taut bands Hct: 0.31 L
Wt: 51 kg VS: Neuro: MCV: 90.4
Ideal BW: 42.4 kg BP: 120/80 mmHg No facial asymmetry on raising eyebrows or MCH: 30.1
PR: 88 bpm grinning MCHC: 332
BP: 90-150/70-80 (150/70) RR: 16 cpm Sensory: 100% on all extremities Plt ct: 322
PR: 64-92 (75) T: 36.8 C Motor: 5/5 on all extremities WBC: 8.7
RR: 13-20 (20) SpO2: 98% at RA Segmenters: 0.68
T: 36.2-36.8 (36.5) Skin: no cyanosis, warm to touch A: Musculoskeletal strain Lympho: 0.28
SPO2: 93-97 (97) 2 lpm/nc C/L: SCWE, no lagging, no retractions, no Eosino: -
wheeze P: Mono: 0.04
I & O : 2458 vs 2000 (+) Coarse crackles at mid to basal lung fields, Suggesting Warm compress over the affected Baso: -
more on the l eft than the right area
CBG (09/22/23) Adjust the elevation of the bed when patient ECG ongoing po docs, will
6 am: 249 A: t/c Hospital Acquired Pneumonia feels uncomfortable relay once done
12 nn: 253 Suggesting to give pain meds if pain worsens
Rescue doses of insulin given P: or becomes intolerable Thank you po docs!
Suggest to do CXR
Skin: (+) sallow skin Suggest Acetylcysteine 600 mg OD in the PM Thank you po doc
HEENT: (+) icteric sclera; diplopia Continue Antibiotics
C/L: (+) minimal bibasal crackles Continue DBE [PICU SVS]
CVS: normal rate, regular rhythm, no murmurs
Abdomen: (+) globular abdomen NABS
hypertympanitic upper abdomen, dull on
WOF: Desaturations, Dyspnea, Fever

Thank you po docs

💊 PICU 1
PICARDAL, ROMEO
flanks, (-) tenderness on abdomen Under Dr. Bacani, Dr. Liban, Dr. Liquete and Dr.
Extremities: (+) hyperpigmentation fingers, (+) Montenegro
bipedal edema grade 1
BP: 110-140/ 70-80 ( 120/80)
Labs: HR: 64-82 (64)
9/21/23 vs 09/19/23 RR: 13-16 (15)
Crea: 0.97 H (2) T: 36.6-37.6 (37.2)
eGfr: 64mL/min/1.73m2 No febrile episodes
SPO2: 93-95% (94 % at RA)
9/21/23 vs 9/18/23
K: 3.88 (4.15) 1/O:
Na: 129 L (127)
09/19/23
Direct Bilirubin : 57.80 H
💊 PICU 2
DUMBRIQUE, JONAH
Total Bilirubin: 74.70 H Under Dr. Liquete and Dr. Padilla
Procalcitonin: 2.580
PTPA: 26.75 H BP: 130-160/70-100 (140/80 at 0.5 mkd Nicard)
HR: 86-114 (83)
ROM: RR: 14-24 (15)
PNSS 1L x 70 cc/hr T: 36.8-38.2 (36.0)
Diet: Low fat, low salt diet Febrile episodes at 3pm (38.2) and 6pm
Nutren 3 scoops in 1 mug/glass of water 2x a (38.0C)
day SPO2: 94-96% (95% at 0.5 Ipm/nc)
Nicard drip: 0.5 mkd
Piperacillin Tazobactam 2.25 gm IV Q6 - D3 6
pm (9/22) 1/O:
Phospholipids OD at lunch
Lactulose (Duphalac) 20ml BID
Livamin OD at PM
Terlipressin 4 mg in PNSS 100cc/soluset to run
for 24 hours - to be consumed
Albumin + Furosemide infusion to be
discontinued once Terlipressin is Consumed
Tramadol 50 mg IV Q8 prn for pain
Carvedilol 6.25 mg 1/2 tab BID. Check BP first
before giving the medication. Do not give if SBP
is less than 120 mm Hg.

ON HOLD:
Losartan 50 mg 1 tab OD AM
Insulin 70/30 36 units in AM, 24units in PM

Thank you po doc!

[7th - DIRECT ADMISSION] [7TH - CP CLEARANCE] [7th - POST-OP UPDATE] [8th - DIRECT ADMISSION CHEMO]
Dalawa dapat - OR done & back to wards
Good afternoon po doctor [CPC] Good morning po doctors
This PGI Manzano, John Kyle, in charge here Good morning po doctors Respectfully informing that this will be the GC
at SLU SHMC, 7th Floor Good afternoon po, doctors. Informing you po for Patient
new CP clearance referral from Dr. Velasquez 1. OR done po for pt. Surname, First Name
Respectfully informing you that Patient referred to Dr. Loranzana po. Patient Currently at PACU with the following VS La Madrid, Yuriko
Wacangan, Juanita is already admitted at this Will update once back to wards po docs 42/F
institution for Total Thyroidectomy tomorrow at CABANA, Rommel Thank you po!
7 AM 38/M Invasive Mammary Carcinoma, Stage IIIA
Currently at ER, Surgery Bed 4 2. Good morning po doctors, Pt SALVADOR, (cT3N1M0), right, s/p Breast Mass Excision,
Patient is already admitted po doc Ethan, back to wards na po Right, with RFS, MRM, Right (08/21/23)
With the following Labs and Imaging (Done as Dx:
OPD) Axillary lymphadenopathy r/o hidradenitis Zygomatic Mass, left s/p Excision of Zygomatic For Chemotherapy
UTZ of the Neck suppurativa, Left Mass, left
ECG for Axillary lymphadenectomy, left tomorrow Relaying the following po docs:
CT-scan of the Abdomen (8/30/29) TF 8 am Perm cath case S: No pain on surgical site, no subjective
Crea, SGPT, Alk Phosphatase, Amylase, complaints Baseline VS:
Lipase AP: Dr. Velasquez BP: 120/70 mmHg
TSH, FreeT3, CA 19-9 CPC: Dr. Lorenzana Latest VS PR: 110 bpm
CBC BP: 130/80 mmHg RR: 19 cpm
Covid RT PCR Hx and PE, ECG, CXR, CBC, crea - ongoing HR:74 bpm T: 36.5 C
2D Echo RR: 19 cpm SpO2: 97% RA
CXR Thank you po, doctors T: 36.6 C
SPO2: 98 at RA Ht: 157.7 cm
CP Evaluation attached to chart (with the Wt: 69 kg
following contents) Dry and intact dressing at the left zygomatic BMI: 27.7
- Cleared for Thyroid Surgery w/ Moderate Risk area BSA: 1.74
- Provide adequate hydration, oxygenation, and
analgesia Thank you po doctors! Ongoing ECG po docs

Thank you po doc! Thank you po docs!