IM CD CENSUS July 2, 2024 (for Printing)

Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE

University of Santo Tomas Hospital
TOTAL PATIENTS: 39
July 3, 2024 (WEDNESDAY)
NEW MAIN PATIENTS (0) NEW REFERRAL PATIENTS (1) MED COMPLEX (14) SURG COMPLEX (25)
BARTOLO
ROQUE
WAGAN MAGLUYAN (M: Neuro R:
217E 203A (M:Pulmo R: Neuro, 217B 227A
(M: Neuro R: Rheuma) (M: Neurosurg R: CV) Endo, Rehab, ENT)
Nephro, CV, ID, Uro)
PEÑAMANTE
(M: MedcOnco; R: GS, SARIO LEE
204A
Anes, FM, Pain Med, 217C (M: Neuro R: CV, 227B (M: Neurosurg R:CV,
Nephro, Neuro, Derma, NeuroSx) Nephro, Hema, ID)
Rad onco, Rehab)
YUMUYA
CRUZ
(M: Pulmo R: Derma, LIBAO
207B 217D 228A (M: Nsx R: Medonco,
Neuro, ENT, ID, (M: NeuroSx R: CV)
IDS, Uro)
Ophtha, Uro)
KALI DEL ROSARIO

WAGAN
207C (IM; CV R: GI, Nephro, 217E 225B (M: Gyne R: Pulmo,
(M: Neuro R: Rheuma)
Pulmo) Nephro, CV, GS)
REYES
LISING MARIANO SLW
207D 219B (M: Psych R: Pulmo,
(M: Nephro, CV R: Uro) (M: NeuroSx R: IDS) 230C
CV)
CHAVEZ
NAKPIL SLW GALENDEZ
208A (M: Hema R: Pulmo, GI, 219C
(M: Neuro R: GI) 231H (M: Psych R: CV)
Ophtha)
LIM
(M: Hema R: GI, Pulmo, JOVENAL SLW LANDERO
208B 220B
ID, Nsx, Neuro, TCVS, (M: ENT R: Endo, Anes) 232 (M: Psych R: CV)
GS)
LAGMAN
(M: Pulmo R: TCVS, SOBRETODO SLW JUCO
209A 220G
Anes, Med Onco, CV, (M: GS R: CV) 234 (M: Psych R CV:)
IDS)
GONZALES VILLONES
SLW SANTOS, B.
210C (M: GI R: CV, Onco, 221B (M: GS R: CV, Endo,
233 (M: Psych R: CV)
GS) Anes)
SAGUIBO
CALPITO SLW RIVERA
210D (M: Hema R: Pain med, 221D
(M: Nsx R: Nephro, CV) 230E (M: Neuropsych R: CV)
Nephro, Rehab)
BALBALOSA
QUIZON SLW BARLAO
211B (M: GI R: CV, Pulmo, 221G
(M: Uro R: Anes, CV) 231I (M: Neuropsych R: CV)
Endo, GS)
UY
PARAGAS
211E 225A (M: Neuro R: CV,
(M: FM R: GI, Endo)
Pulmo, NeuroSx)
LUSUNG
SANTOS, Von
212A (M:ID R: CV, GS, 226A
(M: NSx R: ID, Rehab)
Rehab, PRAS)
SORDILLO
(M: Neuro; R: CV,
LERMA
308 226B Pulmo, ENT, Endo,
(M: Nephro R: ID)
Derma, Fam Med,
Dietary)
TOTAL PATIENTS: 39
MEDICAL COMPLEX (TOTAL: 11; 9M, 2R)
203A 07/02/24 07/01/24 Awaiting:

ROQUE Na 151 H (149) K 4.02 (3.63) CXR
Follow-up examination when compared to the study done on Pending:
06/20/2024 shows significant regression of the interstitial densities in
the right lower lung field Refused:
The heart remains enlarged.
The pulmonary vasculature appears accentuated which may be
positional in nature. Cannot rule out congestive changes.
Aorta is atheromatous. EOLCP in Effect
The right hemidiaphragm is tented.
The right costophrenic sulcus is blunted which may represent
presence of minimal pleural effusion or pleural thickening.
The left hemidiaphragm and costophrenic sulcus are preserved.
A nasogastric tube is again seen with its tip not adequately
visualized.
The rest of the findings are stationary.
204A Tramadol 50mg/IV Q8 PRN 6/22/24 06/20 Awaiting:

PENAMANTE, Rocky Ondansetron 8mg/IV Q12 Na 133 (133) K 4.64 (4.96) CHEST CT
65/M PRN Creatinine 0.58 (0.70) eGFR 108 IMPRESSION: Pending:
Paracetamol 600 mg/IV Q6 HETEROGENEOUSLY-ENHANCING AREAS OF Repeat Na, K, Crea 6/22; RAT on 6/25 10 AM
Oxycodone 2 mg/IV Q12 06/19 CONSOLIDATION-ATELECTASIS AT THE RIGHT UPPER AND
M: Med Onco PRN Hgb 100 RBC 3.44 Hct 0.30 PC 265 WBC 8.60 Neu 0.69 Lym 0.28
R: MIDDLE LOBES EXHIBITING DILATED AIR BRONCHOGRAMS
Rebamipide 100 mg TID Mon 0.01 Eos 0.02
GS Vitamin B Complex OD AND INTRALESIONAL CALCIFICATIONS Refused:
GI Buscopan 10mg/tab Q8 BUN 15.10 AST 29.30 ALT 28.20 Na 133 K 4.96 Crea 0.70 eGFR NON-ENHANCING PARENCHYMAL AND SUBPLEURAL NGT insertion
ANES Meropenem 1g/IV in 90mL 102 NODULES, RIGHT LOWER LOBE Trop-I
FM PNSS q8 RETICULONODULAR DENSITIES, SOME EXHIBITING
Paracetamol 300mg/IV 06/18 TREE-IN-BUD CONFIGURATION, RIGHT LOWER LOBE
Pain Med
Pantoprazole 40mg/cap ABO GROUP RH Typing “B” Positive INTERLOBULAR SEPTAL THICKENING, RIGHT LOWER LOBE
Nephro BID Crossmatching Compatible in 3 phases
ID HETEROGENEOUSLY-ENHANCING ENLARGED AND
Amlodipine 10mg/tab OD
Pulmo Levofloxacin 750mg/tab 06/16 CONFLUENT MEDIASTINAL LYMPHADENOPATHIES, AS
CV q24 AST 32.50 ALT 27.80 Na 138 K 4.10 Crea 0.65 (L) eGFR 104 DESCRIBED
Neuro Carvedilol 25 mg/tab BID *ABOVE FINDINGS MAY REPRESENT AN INFECTIOUS
Derma Fluconazole (Diflucan) CBC Hgb 87L Hct 0.26L RBC 2.98L PC 207 WBC 7.90 Seg 0.82 PROCESS SUCH AS PULMONARY TUBERCULOSIS.
200mg/cap OF Bands 0.01 Metamyelocytes 0.02 Lym 0.08 Mon 0.04 Eos 0.03 CANNOT TOTALLY RULE OUT A NEOPLASTIC PROCESS SUCH
Rad Onco
KCl Syrup 20 meq TID AS PULMONARY LYMPHOMA.
EOLCP (Give all) Loperamide 2g/cap q8 06/15
HISTOPATHOLOGIC CORRELATION IS RECOMMENDED
Telmisartan 40mg/tab OD Yeast specification and sensitivity
Assessment: Kcl syrup 20meeqs Q4H Culture: Candida Tropicalis
AKI ST II sec to 1) Paracetamol 600mg/IV Sensitive to: FLUCONAZOLE VORICONAZOLE AMPHOTERICIN-B
Decreased ECV Q4H Intermediate to: NONE
Tranexamic Acid 500mg/IV Resistant to: NONE 06/05
(Hypovolemic shock) 2) Portable CXR
q8h
Post-operative AKI, Clindamycin 300mg/tab 2 Pneumonia with consolidation, R q
resolving; Colon AdenoCA tab q8h 06/14 Cannot rule out cardiomegaly
ST III; S/P Exlap, repair of KCl syrup 20mEqs q6h Blood with Left Arm: Cannot rule out pleural effusion right
serosal tears, loop Hidrasec 100 mg/cap 1 cap No growth after 5 days of incubation Suggest coinical correlation
ileostomy, jejunostomy, TID
Na 141 K 2.56L Crea 0.62L eGFR 106 06/04
gastrostomy tube isnertion 12L ECG
HR correction scale
(05/23/24); s/p 5 Cycles 1. Sinus rhythm
Incentive spirometry 5x/day HGB 80L RBC 2.74L HCT 0.24L PLT 508H WBC 15.60H N 0.92H L
FOLFIRI (Jan-April 2024) Replace losses from 0.07L M 0.01L 2. Normal 12L ecg
S/P 6 cycles Oxaliplatin & gastrostomy and
Capecitabine (May-Nov jejunostomy v/v PLRS 06/11
2023) Nasal spray TID AST 30.70 ALT 38.80 Na 138.00 K 2.42L Albumin 1.9g/dL 06/03
TOTAL PATIENTS: 39
WAB UTZ
Sepsis prob sec to CBG monitoring OD HGB 100 RBC 3.44 HCT 0.29 PLT 670 WBC 8.50 N 0.92 L 0.07 M The liver is within normal range in size. It exhibits non-uniform echo
nosocomia pneumonia vs pre-feeding 0.01 pattern and increased parenchymal echogenicity. Focal hypoechoic
area is noted in the periportal region. The intrahepatic ducts are not
intrabdominal infection
dilated. The common bile duct measures 0.3
06/10 The gallbladder measures 3.8 x 1.4 cm (L x W). No abnormal
Dermatology’s Urine CS intraluminal echoes nor shadowing seen. The gallbladder wall is not
Assessment: Negative for bacterial growth thickened measuring 0.3 cm.
Trauma-induced erosion Incidental findings: *yeasts isolate The pancreas measures 2.2 cm, 1.2 cm, and 0.9 cm, for the head,
secondary to removal of body, and tail, respectively. Echo Pattern is uniform. No evident solid
durapore tape 06/08 nor cystic mass lesion seen in or at the region of the pancreas. The
BLOOD CS w/ ARD, Right hand pancreatic duct is not dilated.
CULTURE: POSITIVE AFTER 10 HOURS OF INCUBATION - The spleen is not enlarged measuring 5.1 cm along its longitudinal
S/P transfusion of 1u Klebsiella pneumoniae axis. Negative for intrasplenic mass.
PRBC The right kidney measures 10.7 x 3.7 cm (L x W) with a parenchymal
SENSITIVE TO: thickness of 1.5 cm and cortical thickness of 0.8 cm. It exhibits
WOF: Hypotension and CO-AMOXYCLAV normal parenchymal echogenicity. Anechoic foci are seen with the
Desats, Bradypnea CEFUROXIME one in the superior pole measuring 0.5 × 0.4 × 0.5 cm (L x AP x W),
CEFTRIAXONE and the one in the interpolar region measuring 0.4 × 0.7 x 0.5 cm
IMIPENEM (with peripheral calcification, L x AP x W).
S/P POCUS bilateral
GENTAMICIN Negative for lithiasis. The pelvicalyceal complex is not dilated.
hemothorax PIPERACILLIN-TAZOBACTAM The left kidney measures 10.9 x 5.0 cm (L x W) with a parenchymal
CEFOXITIN thickness of 1.6 cm and cortical thickness of 0.7 cm. It likewise
CEFEPIME exhibits normal parenchymal echogenicity. An anechoic structure
MEROPENEM showing posterior acoustic enhancement, septation, peripheral
TOBRAMYCIN calcification with intralesional non-shadowing low level echoes is
CEFAZOLIN identified at the superior pole measuring 2.7 x 2.6 x 3.1 cm (L x AP x
CEFOTAXIME W). Negative for lithiasis. The pelvicalyceal complex is not dilated.
ERTAPENEM
AMIKACIN IMPRESSION:
CIPROFLOXACIN NORMAL SIZED LIVER WITH DIFFUSE PARENCHYMAL
CHANGES THAT MAY BE DUE TO FATTY INFILTRATION
INTERMEDIATE TO: NONE SHOWING A FOCAL AREA OF FAT SPARING.
RESISTANT TO: AMPICILLIN NORMAL-SIZED RIGHT KIDNEY WITH RENAL CORTICAL
CYSTS, AS DESCRIBED.
06/08 NORMAL-SIZED LEFT KIDNEY WITH CYSTIC FOCUS SHOWING
CBC SEPTATION, PERIPHERAL CALCIFICATION AND
HGB 85 (88) HCT 0.26 (0.26) PLT 580 (248) WBC 8.3 (6.6) N 0.91 S INTRALESIONAL CELLULAR DEBRIS AND/OR SEDIMENTS THAT
0.91 (0.94) L 0.08 M 0.01 E - MAY BE ASCRIBED TO A COMPLICATED RENAL CORTICAL
CYST. SUGGEST FOLLOW-UP.
Na 134 (130) K 4.44 (4.68) Crea 0.55 (0.81) eGFR 110 NORMAL SONOGRAM OF THE GALLBLADDER, PANCREAS,
AND SPLEEN.
BLOOD CS w/ ARD, Right hand
06/01
CULTURE: POSITIVE AFTER 10 HOURS OF INCUBATION - PORTABLE CHEST
Aeromonas hydrophilia Ill-defined opacities are seen on both lung fields.
The heart is not enlarged.
SENSITIVE TO: Aorta is tortuous and calcified.
CEFTAZIDIME Diaphragm and both costophrenic sulci are intact.
TMP-SULFAMETHOXAZOLE
CEFTRIAXONE IMPRESSION:
LEVOFLOXACIN P.T.B., BILATERAL, CANNOT RULE OUT CONCOMITANT
CIPROFLOXACIN PNEUMONIA.
ATHEROMATOUS AORTA.
INTERMEDIATE TO: NONE
RESISTANT TO: NONE 06/02
BLOOD CS w/ ARD, Left arm Pelvic X Ray
SACRUM AND COCCYX (AP/LATERAL:
CULTURE: POSITIVE AFTER 9 HOURS OF INCUBATION - No demonstrable radiographic evidence of bone or joint abnormality.
Aeromonas hydrophilia Trabecular pattern, cortical outlines and joint spaces are intact.
There are osteophytes in the anterior aspect of the visualized distal
SENSITIVE TO: lumbar spine.
CEFTAZIDIME A colostomy is noted in the left upper quadrant of the abdomen with
TMP-SULFAMETHOXAZOLE paucity of distal colonic gas.
CEFTRIAXONE A Jackson-Pratt drain is seen overlying the left pelvic region.
LEVOFLOXACIN Surgical staples are appreciated.
CIPROFLOXACIN
TOTAL PATIENTS: 39
INTERMEDIATE TO: NONE

RESISTANT TO: NONE
06/05
Growth after 10hrs on both sides
06/05
Na 130(130) K 4.68 (4.27) Crea 0.81 (0.7) eGGR 98 (102)
Hgb 88(94) Hct 0.26(0.28) Plt 298 (262) WBC 6.60(18.20) N
0.95(0.94) L 0.05(0.05)
06/04
CBC HGB 94 HCT 0.28 PLT 362 WBC 18.2 N 0.94 S 0.94 L 0.05 M
0.01 E
05/30
Na 133 (135), K 3.18 (3.8)
05/28
Hgb 109 (137), Hct 0.31 (0.41), Plt 204 (341), Wbc 9.3 (38.5), N 0.88
(0.96), L 0.1 (0.07)
206A Salbutamol + Ipratropium 1 06/22 06/19 Awaiting:

BUNGAY, Rosario neb Q6 Chest CT -TSH T3 T4, 12L ECG
56/F Hydrocortisone 100mg IV UA: Dark yellow slight Turbid pH 6.5 SG 1.015 Albumin 2+ Sugar 1+ IMPRESSION:
Q12 Leukocyte Pos Erythocyte Pos Bilirubin Neg Nitrite Neg Ketone Pos •AREA OF CONSOLIDATIONS WITH INTRALESIONAL Pending:
Co-managed: Pulmo and Piperacillin-Tazobactam Urobilinogen 1+ RBC 3-6 Pus 1-3 Yeast Cells few Squamous + CALCIFICATION, CAVITARY FORMATIONS AND TRACTION - MTB C&S
Endo 4.5g/IV in 90cc Renal cell - Transitional Epithelial Cell - Bacteria ++ Mucus + -For CT Stono, FRCT
BRONCHIECTASIS IN BOTH LUNGS, AS DESCRIBED
Referrals: Uro NAC 600mg/tab 1 tab BID Amorphous urates - UA - Calcium oxalate - Amorphous phosphate - -Sputum AFB Smear
HRZE (dose to follow) Triple Phosphate - Hyaline 07 Granular - Waxy - RBC Cast - WBC RETICULONODULAR DENSITIES EXHIBITING TREE IN BUD -CBC PC, Crea, ALT, AST
Assessment: CAP- MR Meropenem 1g/Iv in 90cc cast - remarks: no dysmorphic rbc seen CONFIGURATION IN BOTH LUNGS, AS DESCRIBED. -Urine GS/CS, UA (6/22)
with MDR risk. COPD in PNSS q8h 1 CONFLUENT LYMPH NODES, RIGHT PARA TRACHEAL,
acute excerbation. PTB Podevta 10u/SC OD 06/17 SUBCARINAL AND BOTH HILAR REGIONS.
clinically diagnosed. DM Vildagliptin 50mg after CBC HGB 105 (L) RBC 3.70 (L) HCT 0.32 (L) PLT 405 (H) WBC 18 2 LYTIC CHANGES OF T10 AND T12 VERTEBRAE.
Type 2 poorly controlled meals BID (H) N 0.91 L 0.08 M 0.01 *ABOVE FINDINGS MAY REPRESENT AN INFECTIOUS
Gliclazide 60mg/tab (before
PROCESS SUCH AS PULMONARY AND EXTRAPULMONARY
breakfast) OD Blood Chemistry
Salbutamol +Ipratropium Na 132(L) K 3.42(L) TUBERCULOSIS.
Neb NON CALCIFIED SUBPLEURAL NODULE EXHIBITING PLEURAL
Budesonide tab Q12H ABG TAGGING IN THE RIGHT UPPER LOBE.
Apidra premeals 4 u TID pH 7.52 pCO2 36.10 pO2 75.90 HCO3 29.80 FiO2 21% O2 Sat NON CALCIFIED PARENCHYMAL NODULES, BOTH LUNGS.
SC 96.30% BE 7.30 RR 24 pf ratio 361.43 dFiO2 21.79% aAO2 0.73 a-A CALCIFIED GRANULOMA, LEFT UPPER LOBE.
Ivabradine7. 5 mg/tab BID gradient 28.71 PATCHES OF GROUND GLASS OPACITIES IN THE RIGHT
Gliclazide 60mg/tab 1 tab Interpretation:
UPPER LOBE. THIS MAY RERPESENT AN INFECTIOUS
BID Uncompensated Metabolic Alkalosis with Hypoxemia On Room Air
KCl TID PROCESS.
Celecoxib 200mg/tab BID 06/11/2024 SUBSEGMENTAL ATELECTASIS, RIGHT LOWER LOBE.
HNBB Q8H Sputum Gram Stain: G+ cocci in pairs: Few LINEAR FIBROSES, BOTH LUNGS.
Vitamin B OD PMN leukocytes: more than 25/LPF PLEURAL EFFUSION WITH ASSOCIATED PASSIVE
HRZE 3 tabs OD Squamous epithelial cells: 5-10/LPF ATELECTASIS, RIGHT.
ATHEROSCLERO TIC VESSELS.
CBG monitoring HYPERTROPHIC DEGENERATIVE CHANGES OF THE
Apidra correction scale THORACOLUMBAR SPINE
06/14
KUB-UTZ
The right kidney measures 9.6 x 5.3 cm (L x W) with a parenchymal
thickness of 1.9 cm. It exhibits normal parenchyma echogenicity. No
evident solid nor cystic mass lesion is appreciated. Negative for
lithiasis. The pelvocalyceal complex is slightly dilated.
The left kidney measures 10.1 × 5.6 cm (Lx W) with a parenchymal
thickness of 2.2 cm. It likewise exhibits normal parenchymal
echogenicity. No evident solid nor cystic mass lesion is appreciated.
TOTAL PATIENTS: 39
Negative for lithiasis. The pelvocalyceal complex is not dilated

IMPRESSION:
PELVO-CALIECTASIS, RIGHT.
LEFT KIDNEY - NEGATIVE.
06/13/24
WAB UTZ
The liver is within normal range in size. It exhibits uniform
echopattern and normal parenchymal echogenicity. No evident focal
echo defect seen. The intrahepatic ducts are not dilated. The
common bile duct measures 0.3 cm.
The gallbladder measures 4.5 x 2.6 cm/(L x W). No abnormal

intraluminal echoes nor shadowing seen. The gallbladder wll is not
thickened measuring 0.2 cm.
The pancreas measures 1.8 cm, 1.0 cm, and 1.0 cm, for the head,
body, and tail, respectively. Echopattern is uniform, No evident solid
nor cystic mass lesion seen in or at the region of the pancreas. The
pancreatic duct is not dilated.
The spleen is not enlarged measuring 6.9 cm along its longitudinal

axis.
Negative for intrasplenic mass.
IMPRESSION:
LIVER, GALLBLADDER, PANCREAS, SPLEEN- NEGATIVE.
06/10
CHEST XRAY
There are reticulo-nodular densities seen in both upper lung fields
and right infrahilar region
Right hilum is tracted upward
Heart is not enlarged
Diaphragm and both costophrenic sulci are intact
IMPRESSION:
PTB, BILATERAL. CANNOT RULE OUT CONCOMITANT
PNEUMONIA. SUGGEST CLINICAL AND LABORATORY
CORRELATIONS.
207A Colchicine 500mg/tab OD 06/19 06/16 Awaiting:

CARCHA, FERNANDO Omeprazole 40mg/cap OD AST 45.80H ALT 49.60 Na 133 K 3.74 CHEST XRAY - Blood CS x 2 sites
JR. Norgesic Forte PRN Q8 - Progression of the interstitial infiltrates in the Right Pericardiac - MTB Genexpert (Sputum)
Paracetamol 500mg/tab 06/16
23/M region now also seen in the Left lower lung field. These are
PRN pH 7.529 pCO2 25.4 pO2 102.4 HCO3 21.4 a/A 0.6 Pending:
HRZE 4tabs OD attributed to a pneumonic process - Sputum GS then CS if PMN > 25 & SEC < 10
Main Service: Pulmo, Vitamin B complex OD 06/13 - Heart appears enlarged - IGRA
Referrals: ID Transmetil 500mg/tab TID Hgb 101 (L) RBC 4.55 (L) Hct 0.31 (L) PC 228 WBC 12.30 (H) N - The Left Hemidiaphragm and Costophrenic are discarded still - For perimetry, OCT-RNFL 2 months after HRZE
Ophtha Ivabradine 7.5mg/ tab BID 0.74 L 0.22 M 0.03 E 0.01 indicating presence of Pleural Effusion initiation
CV Paracetamol 300mg//Iav q4 - The right hemidiaphragm and costophrenic remain intact - Peripheral blood smear
PRN for fever Uric Acid 7.00 AST 17.20 ALT 17.80 Na 127 (L) K 4.31 Crea 0.52 (L) - Repeat CBC PC,
Ceftolozane Tazobactam eGFR 145 - For POCUS at LE
Assessment:
1.5g/IV in 90cc PNSS q8 - For MDM
CAP-MR. T/c TB Levofloxacin 750mg/tab 1 Interferon Gamma Test for TB: POSITIVE -Chest UTZ (6/22)
lymphadenitis. PTB tab OD
Presumptive Carvedilol 6.25mg/tab BID 06/11 06/06
NAC 600mg/tab in ½ glass Blood with ARD, left arm CS: No growth after 5 days of incubation PORTABLE CHEST
water BID Follow-up examination when compared to study done on 4/2/2024
Ophthalmologic shows heart is not enlarged.
Assessment: Salbutamol + Ipratropium 06/06
Neb Urinalysis There is interval development of hazed densities in the left lower
Normal fundus at the time lung field which may represent a pneumonic process.
Methylprednisolone YELLOW, SL. TURBID pH 7.0 Specific Gravity 1.010 Albumin 1+
of Examination, both eyes 16mg/tab BID Sugar Negative Leukocytes Negative Erythrocytes Negative Bilirubin Diaphragm and costophrenic sulci are intact
The rest of the findings remain unchanged
TOTAL PATIENTS: 39
Naproxen 275mg/tab 1 tab Negative Nitrite Negative Ketone Negative Urobilinogen 1+ Red
TID Blood Cell 0-3 Pus Cell 0-2 Squamous Cell FEW Bacteria (+)
Mucus Threads FEW Amorphous Urates FEW 04/03
2D-Echo
EF Simpsons: 70
06/05 Normal LV geometry with notmal resting systolic and diastolic
CBC function. Normal RV size and function. Normal Left and right atria.
Hgb 121 Hct 0.39 Plt 338 WBC 17.19 N78 L 12.30 M 9.30
CRP >5 Positive
207B Piperacillin Tazobactam 4.5 06/19 06/17 Awaiting:

Yumuya, Roberto g/IV in 90mL PNSS q6 Na 129L K 3.94 Portable Chest -Urine CS
74/M Azithromycin oral PORTABLE CHEST -Yeast Speciation
Suspension 12.5 mL 06/18 Ill-defined densities are seen in both upper lung fields.
200/5mL OD Blood Chemistry The heart is magnified in size. Pending:
Main Service: Pulmo NAC 600mg.tab in ½ glass Na 128 (L) K 3,85
Referral: Derma, ENT Aorta is segmentally calcified and tortuous.
of H2O
Pantoprazole 40mg/cap OD Diaphragm and both costophrenic sulci are intact.
Assessment: CAP-MR, Enoxaparin 0.4 mL/SQ OD A tracheostomy tube is seen with its tip at the level of
Consider Aspiration Terbinafine 250mg/tab OD Т3-74.
Component A nasogastric tube is appreciated with its tip overlying the gastric
Salbutamol + Ipratropium region.
Derm Assessment:
neb q8 IMPRESSION
Tinea Pedis Oral care with
CONSIDER PULMONARY TUBERCULOSIS VERSUS
Chlorhexidine TID
NSS compress on right foot PNEUMONIA, BOTH UPPER LUNGS,
TID MAGNIFIED CARDIAC SIZE
Betamethasone valerate ATHEROMATOUS AORTA
cream, on erythematous
areas thinly BID WAB CT
HEPATOMEGALY.
CONTRACTED GALLBLADDER.
DILATED SMALL INTESTINAL SEGMENTS WITH NO EVIDENT
POINT OF OBSTRUCTION. CONSIDER ILEUS VERSUS
BEGINNING SMALL BOWEL OBSTRUCTION. SUGGEST
CORRELATION WITH CLINICAL FINDINGS.
STATUS POST APPENDECTOMY.
MESENTERIC, PELVIC AND RECTOSIGMOID FAT STRANDINGS
MAY BE DUE TO AN INFECTIOUS OR INFLAMMATORY
PROCESS.
CALCIFIED PARACAVAL LYMPH NODE.
PLEURAL AND SUBPULMONIC EFFUSION, RIGHT.
PERIHEPATIC ASCITES.
MINIMAL HYPERTROPHIC DEGENERATIVE CHANGES OF THE
THORACIC SPINE.
INCIDENTAL FINDINGS.
1 PARTIALLY VISUALIZED HETEROGENEOUSLY ENHANCING
LESION IN THE RIGHT LOWER LUNG WITH AREAS OF
NECROSIS.
2 NON-ENHANCING SUBPLEURAL NODULES.
RETICULONODULAR DENSITIES IN THE VISUALIZED RIGHT
LUNG
ABOVE FINDINGS ARE SUGGESTIVE OF AN INFECTIOUS
PROCESS SUCH AS TUBERCULOSIS HOWEVER THE
POSSIBILITY OF A NEOPLASTIC PROCESS IS STILL
CONSIDERED. A DEDICATED STUDY MAY BE DONE FOR
FURTHER EVALUATION.
TOTAL PATIENTS: 39
207C KALI Ceftriaxone 2g/IV in 90cc 06/23 Awaiting:

Main: CV PNSS q24h Sputum GS Pending:
Referral: Levopres 10mL TID Gram (+) cocci in pairs few
GI, Nephro, Pulmo Azithromycin 500ng/tab 1 Polymorphonuclear leukocytes >25/lpf
tab q24h Squamous epithelial cells 5-10/lpf
Assessment: Tamsulosin + Finasteride
CAP-MR; AKI st. 2 sec to 200mg/5mg/tab OD BUN 71.30 (63.70) Uric acid 17.20 Na 131 (129) K 3.15 (3.36) Cl
1.) volume depletion Lactitol 30cc OD 96.20 iPhos 5.27 iCa 1.11 Crea 2.43 (2.60) eGFR 26 (24)
2.)infection 3.)r/o CRS
liver cirrhosis, not in acute UA: dark yellow, sl turbid, 5.0, 1.020, albumin neg, sugar neg, leu
decompensation state, neg, ery neg, bilirubin neg, nitrite neg, ketone neg, urobilinogen
Child Pugh B normal, rbc 0-3, pus 0-3, squamous cell +, bacteria ++, amorphous
urates -, hyaline cast -, granular cast -
Hgb 107, Hct 0.32, Plt 250, WBC 11.20, N 0.71, L 0.24, M 0.03, E
0.02, B -
207C ZARASPE Piptazo 4.5g/IV 6/19/24 06/19 Awaiting:

Main: Pulmo HRZE tab Fecalysis Chest CT Scan Crea
Referral: Azithromycin 500mg/tab IMPRESSION:
GS Vitamin B Complex OD Green, watery Muscle fiber - Pending:
HETEROGENEOUSLY-ENHANCING AREAS OF
Vegetable cell few Vegetable fiber few Starch granules few Yeast cell -For Bronchoscopy tom
Assessment: few CONSOLIDATION-ATELECTASIS AT THE RIGHT UPPER AND
Small bowel RBC + Pus cell OVER 100 Mucus ++ MIDDLE LOBES EXHIBITING DILATED AIR BRONCHOGRAMS
obstruction; CAP-MR Negative for Ova and Parasites AND INTRALESIONAL CALCIFICATIONS
NON-ENHANCING PARENCHYMAL AND SUBPLEURAL
Sputum C/S NODULES, RIGHT LOWER LOBE
SENSITIVE TO : RETICULONODULAR DENSITIES, SOME EXHIBITING
AMPICILLIN, CEFUROXIME, CEFTRIAXONE
TREE-IN-BUD CONFIGURATION, RIGHT LOWER LOBE
MEROPENEM
TOBRAMYCIN INTERLOBULAR SEPTAL THICKENING, RIGHT LOWER LOBE
CO-AMOXYCLAV HETEROGENEOUSLY-ENHANCING ENLARGED AND
CEFOXITIN CONFLUENT MEDIASTINAL LYMPHADENOPATHIES, AS
ERTAPENEM DESCRIBED
AMIKACIN *ABOVE FINDINGS MAY REPRESENT AN INFECTIOUS
CIPROFLOXACIN PROCESS SUCH AS PULMONARY TUBERCULOSIS.
PIPERACILLIN-TAZOBACTAM
CANNOT TOTALLY RULE OUT A NEOPLASTIC PROCESS SUCH
CEFOTAXIME
IMIPENEM AS PULMONARY LYMPHOMA.
GENTAMICIN HISTOPATHOLOGIC CORRELATION IS RECOMMENDED
LEVOFLOXACIN
INTERMEDIATE TO: NONE 06/17
RESISTANT TO: NONE CXR
Homogeneous density is demonstrated in the right upper lobe with
upliftment of the minor fissure
Minimal hazy opacities are seen in the right mid lung field.
Diaphragm and both costophrenic sulci are intact.
IMPRESSION
PNEUMONIA, RIGHT WITH CONSOLIDATION AND ATELECTASIS
IN THE RIGHT UPPER LOBE. TO EXCLUDE MASS LESION.
SUGGEST CLOSE INTERVAL FOLLOW-UP OR CHEST CT SCAN
CORRELATION.
WAB CT
The liver is enlarged measuring 16.1 cm and shows homogeneous
parenchymal enhancement. The intrahepatic ducts are not dilated.
No mass is seen. The portal vein measures 1.3 cm.
The gallbladder is contracted.
The pancreas is normal in size. No evident mass seen. The
pancreatic duct measures 0.3 cm.
The spleen and both adrenal glands are unremarkable.
The appendix is not visualized, consistent with history of surgery.
TOTAL PATIENTS: 39
(s/p Appendectomy)
Both kidneys show evidence of function with no structural deformity.
Both pelvocalyceal structures and ureters are not dilated.
The urinary bladder is distended with no intravesical density noted.
The urinary bladder wall is not thickened
Prostate gland measures 4.1 x 2.4 x 2.8 cm (AP × W x H) with an
approximate volume of 14.4 cc.
Hypodense fluid collections are noted the right lower hemithorax and
its adjacent subpulmonic and perihepatic regions.
Minimal hypertrophic spurs are seen at the superior endplates of the
T10 and T11 vertebral bodies.
207D MATEO Febuxostat 40mg/tab 06/19 Awaiting:

PORTABLE CHEST
Main Service: Nephro Follow-up examination when compared to study done several hours Pending:
Referrals: -Na, K, Crea, BUN tom
prior shows interval progression of the hazed densities in the left
-Possible HD 6/22
Assessment: lower lung field.
AKI ST III primary to There is interval development of Interstitial infiltrates in the right
interstitial nephritis paracardiac region.
Reticulonodular densities are seen in the left upper lung field
obscured by overlying bones, apicolordotic view is suggested.
Thin linear densities are now seen in the left lower lung field which
may represent fibrosis.
The pulmonary vascular markings are slightly accentuated.
Aorta is atheromatous.
A right-sided internal jugular catheter is again appreciated with its tip
in the the right atrium.
Diaphragm and right costophrenic sulcus are intact.
Left costophrenic sulcus is blunted, this may represent minimal
pleural effusion and/or thickening.
208A Paracetamol 300mg/IV Q4 06/18 06/14 Awaiting:

MARAYAG, Lilia PRN Na 142 K 3.64 Mg 1.88 Crea 0.97 eGFR 73 CxR
47/F Cetirizine 10mg/tab ODHS Lung Fields are clear. The heart is enlarged. Aorta is calcified and Pending:
Piperacillin Tazobactam 06/14 MGH (6/22)
tortuous. Diaphragm both costophrenic Sulci are intact
Main Service: ID, Derma 4.5g/IV Q6 CBC Hgb 108 (L) (100) RBC 4.61 (4.28) Hct 0.34 (L) (0.31) PC 385
Referrals: Terbinafine 250mg/tab OD (640) WBC 7.80 (10.60) N 0.84 (0.68) L 0.13 (0.24) M 0.02 (0.01) E Cardiomegaly; Atheromatous
Chlorhexidine degluconate 0.01 (0.07)
Assessment: 4% skin solution 06/01/24
Skin and Soft Tissue Mupirocin ointment on UA: Yellow Sl. Turbid pH 6.0 SpGr 1.015 Albumin - SUgar - PORTABLE CHEST
Infection, Severe sec to nostril for 10 days straight Leukocytes - Erythrocytes - Ketone + RBC 0-2 Pus 0-3 Squamous + Lung fields are clear.
Fungal vs Parasitic each month for next 3 Bacteria Few A.Urate Few Cast - The heart is not enlarged.
Infection (prob scabies) months
Aorta is tortuous and calcified.
with superimposed Chlorhexidine bath for each Na 140 (134) K 2.88 (L) (3.52) Crea (1.04 (H) (0.71) eGFR 67 (105)
bacterial infection month for 3 months Diaphragm and both costophrenic sulci are intact.
(cellulitis); Cellulitis, Tinea Tramadol 50mg/IV Q8 for 06/13 IMPRESSION:
Incognito pain Crea 1.15 (H) eGFR 59 ATHEROMATOUS AORTA.
Co-management with Vancomycin 500mg/IV in
Derma 90mL PNSS Q12 06/11 06/01
ID Assessment: Bullous Ciprofloxcin 500mg/tab 1 ½ Crea 0.71 eGFR 105 ELECTROCARDIOGRAPHIC DIAGNOSIS
Cellulitis, Bilateral LE; tab q12 1. Sinus rhythm
Tinea corporis, pedis Doxycycline 100mg/cap 06/07
2. Abnormal precordial R wave progression
q12 Inguinal swab positive for MRSA
WOF:
Contact Precaution! Bactolin wash prior to wet 06/06
TOTAL PATIENTS: 39
to dry dressing with PNSS Blood CS, Bilateral: No growth after 5 days
MGH Wet to dry dressing CBC: Hgb 100 Hct 4.24 PC 640 WBC 10.60 N 0.68 L 0.24 M 0.01 E
0.07
06/02
FPG 107.7 TC 190.9 TG 136.9 HDL 38.2 LDL 134.1 Hba1c 5.77
Color: Dark Yellow, Transparency: Slightly Turbid, pH 6.0, Spec Grav
1.020, Alb 2+, Sugar Neg, Leukocytes Neg, Erythrocytes Positive,
Bilirubin Positive, Nitrite Neg, Ketone Positive, Urobilinogen 1+,
Microscopic Findings: CELLS, RBC 1-3 hpf, Pus Cells 1-3 hpf, Yeast
-, Squamous cells + , Renal cell -, TEC -, Bacteria +++, Mucus
threads ++++, CRYSTALS, Amorphous urates ++, No casts
06/01
BUN 13.60 (9.00-23.00), AST 25.80 (</= 32.00), ALT 23.30 (</=
31.00), Na 134 L (136.00-145.00), K 3.52 (3.50-5.10), Crea 0.70
(0.51-0.95), eGFR 107, CBC Hgb 104 (120-160) RBC count 4.44
(4.0-5.4) Hct 0.32 (0.37-0.43) MCV 71.50 (80-90) MCH 23.40 (28-32)
MCHC 32.60 (30-36) RDW 14.30% (11.6-14.6) PC 289 (170-400)
WBC count 8.80 (4.0-10) N 0.75 (0.50-0.70) no bands, L 0.23
(0.25-0.35) M 0.02 (0.03-0.06) E - B -
208B Awaiting:
DUDAS Pending:
Main: Pulmo
Referral: Endo
Assessment: CAP-MR;
Presumptive PTB; DM
type 2
210A Meropenem 1g/IV in 90cc 06/23 06/20 Awaiting:

AMARO. Roxanne PNSS q12 PORTABLE CHEST - Bacterial GSCS, AFB Stain, Fungal stain, MTB
38/F Paracetamol 300mg/IV q4 Hgb 85 (93), Hct 0.27 (0.29), Plt 230 (165), WBC 17.40 (32.20), N Interstitial infiltrates are seen in the right perihilar region which may Genexpert, myocobacterial CS
PRN 0.64 (0.89), L 0.30 (0.09), M 0.01 (0.02), E 0.05 (-), B - (-) represent a pneumonic process. -Blood CS X 2 Sites
Main : GI Ketoanalogue 600mg/tab
Referral: Endo IDS, TID Alkaline Phosphatase 670 (511) AST 27.90 (21.60) ALT 17.20 Pending:
Nephro, IR NaHCO3 650mg/tab 1 tab (31.70) Total bilirubin 1.03 (2.31) Direct bilirubin 0.83 (2.27) Indirect The right hemidiaphragm is elevated. CBC, AST, ALT, Alkaline Phosphatase, Total
TID bilirubin 0.19 (0.04) Crea 2.64 (2.66) eGFR 23 (23) The left hemidiaphragm and both costophrenic sulci are intact. Bilirubin, B1, B2, Crea (6/23)
Assessment: Intra Kalium Durule 1 tab TID
Abdominal Infection r/o Meropenem 500mg/IV Q12 6/22/24 06/18
Abscess vs Cholangitis; Paracetamol 600mg/IV BILE with ARD C and S VITEK WAB UTZ
AKI Stage 2 Secondary Q6H Proteus Mirabilis: Positive after 6 hrs of incubation
to Infection (t/c Intra Paracetamol 500mg/tab Sensitive to: NORMAL SIZED LIVER WITH DIFFUSE PARENCHYMAL
Abdominal Infection) on Q6H Ampicillin Cefuroxine Ceftriaxone Meropenem Tobramycin CHANGES THAT MAY BE DUE TO FATTY INFILTRATION
top of CKD sec to DKD Ketorolac 30mg/IV Q6H Co-Amoxiclav Cefoxitin Cefepime Amikacin Ciprofloxacin Pip-Tazo STATUS POST ERCP WITH BILIARY STENT INSERTION
Celecoxib 200mg/cap BID Cefotaxime Erapenem Gentamicin Levofloxacin CONTRACTED GALLBLADDER
Ondasetron 4mg/IV Q8H Intermediate to: None NON-VISUALIZED PANCREAS DUE TO OVERLYING BOWEL GAS
Resistant to: Imipenem Tetracycline NORMAL-SIZED KIDNEYS WITH DIFFUSE PARENCHYMAL
CHANGES, BILATERAL. SUGGEST CORRELATION WITH
6/22 CLINICAL AND LABORATORY FINDINGS
BILE with ARD NORMAL SONOGRAM OF THE SPLEEN
C ans S VITEK
Klebsiella Pneumoniae: Positive after 6 hrs of incubation
Sensitive to:
Co-Amoxiclav Cefuroxine Ceftriaxone Meropenem Tobramycin
Pip-Tazo Cefoxitin Cefepime Amikacin Ciprofloxacin Cefazolin
Cefotaxime Ertapenem Gentamicin
Intermediate to: Imipenem
Resistant to: Ampicillin
6/22
Na 138 K 3.59 Crea 2.66 (3.38) eGFR 23 (17)

TOTAL PATIENTS: 39
06/18
UA: :Dark Yellow Turbid pH 5.0 SpGr 1.015 Albumin 4+ Sugar -

Leukocytes + Erythrocytes + Bilirubin + Ketone - RBC 20-25 Pus
60-70 Squamous 4+ Bacteria 4+ A.Urate + Ca Ox + Few Granular
OVER 50 Waxy OVER 50
Alk Phos 511 (H) AST 21.60 ALT 31.70 (H) TOt Bili 2.31 (H) DIr BIli
2.27 (H) Indir Bili 0.04 (L) Na 134 (L) K 3.27 (L) Crea 3.77 (H) eGFR
15
CBC Hgb 111 (L) RBC 4.11 Hct 0.35 (L) PC 216 WBC 27.30 (H) N
0.94 (H) L 0.05 M 0.01
210B Meropenem 1g/IV Q8 6/22/24 06/18 Awaiting:

CRUZ-TORIDA, Celecoxib 200mg/cap BID CBC WAB-CT - EGD
Sharmira PRN for pain GALLBLADDER BILE SLUDGE - Blood CS X Histopath
Hgb 78(77) RBC 2.92(2.87) HCT 0.24 (0.20) MCV 81.0(81.2) MCH
25/F Godex tab 1 tab TID SPLENOMEGALY WITH PROMINENT PORTAL AND SPLENIC -UTZ bilateral knees
Vancomycin 2g/IV in 90mL 26.50(27.00) MCHC 32.70 (33.20) RDW 16.40 (15.30) MPV -IGRA
VEINS. SUGGEST CLINICAL CORRELATION
Main Service: ID PNSS x 2-3 hours 8.20(6.50) PLT 201 (236) WBC 7.50 (21.80) N 0.63 (0.88) S RENAL CORTICAL CYST, LEFT (BOSNIAKI)
Referrals: Omeprazole 40 mg/cap 1 0.61(0.80)L 0.37 Pending
Rheuma cap OD FECAL STASIS
Hema Paracetamol 500mg/tab prn CONSIDER MESENTERIC CYST, AS DESCRIBED
6/22/24
for fever UTERINE MYOMA. TRANSVAGINAL/TRANSRECTAL SONOGRAM
Assessment: Methylprednisolone AST 136.60 (139.10) ALT 153.90 (93.60) Na 134.00 (136) K 4.51 IS RECOMMENDED IF CLINICALLY WARRANTED
t/c Reactive Arthritis; 16mg/tab 2 tabs arter (3.50) Crea 0.34 (0.50) eGFR 146 (133) BILATERAL PERINEPHRIC AND MESENTERIC FAT
Anemia2 to occult GI breakfast STRANDINGS MAY RELATE TO AN
bleeding; anemia of Calcium Carbonate+Vit.D Alkaline Phosphatase 99.00 INFECTIOUS/INFLAMMATORY PROCESS
chronic inflammation, r/o 600 mg per 1000mg/tab
prca BID 06/18 MULTIPLE ENHANCING ABDOMINAL AND IN GU INAL
Bilastine 20mg/tab 1 tab High Secsitive CRP 50.95 (H) Rheumatoid Factor 13.60 LYMPHADENOPATHIES DIFFUSE SUBCUTANEOUS EDEMA, AS
WOF: OD ESR 40mm DESCRIBED
GI bleeding Diphenhydramine GENERALIZED SKIN THICKENING MAY RELATE TO
50mg/cap ODHS 06/17 ERYTHEMATOUS SKIN LESIONS
Methylprednisolone 1g/IV BMA MTB GeneXpert: MTB Not Detected
OSTEOPHYTOSIS, L5 VERTEBRAL BODY INCIDENTAL
Tramadol 500mg/tab 1 tab Bone Marrow Asperate With ARD CS: No Growth After 5 Days
FINDINGS OF THE FOLLOWING:
TID
Minophagin 40mg/IV OD 1 FIBROSIS, RIGHT LOWER LOBE
06/16 2 SUBSEGMENTAL ATELECTASIS, LEFT LOWER LOBE
CBG monitoring OD Hgb 71 RBC 2.73 Hct 0.22 PC 210 WBC 27.80 Seg 0.80 Bands 0.09
Metamyelocytes 0.01 Lym 0.07 Mon 0.03 06/11
2D Echo with DS
Crea 0.42 N LVG w NRSF & DF
eGFR 139 N R v SF
N LA RA
ABO Typing “B” Positive Mild MR
Crossmatching compatible in 3 phases 1 unit pRBC Mild PR
LPPAA
06/13 Minimal Pericardial effusion
ANA Positive up to 1:40 speckled
AST 139 (H) AKT 93.60 (H) Total Bilirubin 0.38 DIrect Bilirubin 0.26
Indirect Bilirubin 0.12 (L) Crea 0.45 (L) eGFR 137
Hgb 77 (L) RBC 2.87 (L) Hct 0.23 (L) MCV 81.20 MCH 27 (L) MCHC
33.20 RDW 15.30 (H) MPV 6.50 PC 236 WBC 21.80 (H) N 0.88 L
0.10 M 0.02
Blood with ARD, Left Arm C/S: No growth after 5 days

Blood with ARD, RIght Arm C/S: No growth after 5 days
06/12
Anti-nuclear antibody: Positive up to 1:40; Speckled
VTL 7.30ug/mL
TOTAL PATIENTS: 39
06/11
Ferritin 38,235 HIGH
06/10
Uric acid 3.70, VTL 8.40
Hgb 73, Hct 0.22, Plt 304, WBC 17.4, N 0.87, B 0.03, S 0.84, L 0.10,
M 0.01, E 0.02
06/09
Stool FIT negative
06/08
BUN 9.80 AST 175.10 ALT 161.40 Na 136 K 3.60 Crea 0.50
210C Paracetamol 500mg/tab, 1 06/21 06/06 Awaiting:

BAYER, Mercy tab q6 PRN for pain Crea 0.62, eGFR 110 RIGHT FOOT
48/F Tramadol 50mg/IV q6 PRN A complete fracture is noted involving the proximal shaft of the 5th Pending:
for moderate to severe pain Hgb 115, Hct 0.33, Plt 261, WBC 5.60, N 0.63, L 0.31. M 0.03, E metatarsal bone. MGH (6/23)
Main Service: Ortho Ondansetron 4mg/IV q8 0.03 A suspicious cortical fracture is appreciated at the base of the 3rd
Referrals: PRN for PONV metatarsal bone.
CV - clearance Enoxaparin 0.4ml/sc OD 06/17 Likewise, an oblique fracture is noted in the proximal phalanx of the
Anes Ampicillin-Sulbacatam 3g/IV Blood with ARD, Right Arm CS: No growth after 5 days incubation 5th digit.
ID in 90cc PNSS for 1-2 hrs q6 The rest of visualized bony structures are unremarkable.
Cefepime 2g/IV in 90cc Wound Tissue, Right Foot Enterococcus Faecalis, CS:
Assessment: PNSS Sensitive to: Ampicillin Penicillin Gentamicin Vancomycin Linezolid 06/05
Fracture open complete Amlodipine 10 mg/tab 1 tab Intermediate to: None RIGHT FOOT
displaced, Proximal 5th OD Resistant to: None Follow-up examination when compared to the study done on
Phalanx Foot, R; Avulsion Vancomycin 1.2g/IV in 90cc 5/4/2024 shows metallic pins seen transfixing the complete fracture
injury Foot, Right; PNSS q12 Wound Tissue Right Foot MTB GeneXpert: MTB Not Detected of the proximal 3rd of the 5th right matatarsal and another transfixing
Fracture open complete Celecoxib 200mg/cap BID the oblique fracture of the 5th right proximal phalanx with no
displaced 5th metatarsal Paracetamol 500mg/tab q6 06/14 evidence of hardware compromise and/or loosening. The fractured
Foot, Right PRN Wound Tissue Right Foot AFB/GS: segments are in good anatomical alignment with no evidence of
s/p Wound debridement Ondansetron 4mg/IV q8 AFB Stain: No acid fast bacilli seen callus formation.
(Dorsum of foot); Celecoxib 200mg/cap GS: No microorganism seen The cortical fracture of the base of the 3rd right metatarsal bone is
Cellulitis, R Foot again noted.
06/13
Na 138.0 K 3.65 Crea 0.66 eGFR 108
Primary closure - medial
aspect and plantar aspect 06/13
of the toes and the Hgb 128 RBC 4.18 Hct 0.37 MCV 89.50 MCH 30.70 MCHC 34 .30
percutaneous of proximal PC 399 WBC 9.00 Seg 0.63 L 0.31 M 0. E 0.04
phalanx and metatarsal -
5th digit foot right 06/11
VTL 8.40 Crea 0.68 eGFR 107
S/p Wound debridement 06/10
with primary Wound CS
closure--foot-right No growth after 5 days incubation
(06/14/24)
06/08
MGH on 06/21 Wound tissue, Right foot
(+) A. baumanii mod growth
Sensitive to Cefepime, Gentamicin, Levofloxacin, Imipenem,
Tobramycin, TMP-SMX, Minocycline, Amikacin, Ciprofloxacin,
Sulbactam-Ampicillin
Intermediate to Piperacillin-Tazobactam, Ceftazidime
Resistant to Meropenem
Wound tissue, Right foot

(+) S. sciuri heavy growth
Sensitive to Linezolid, Vancomycin
Intermediate to None
Resistant to Penicillin, Clindamycin, Oxacillin, Tetracycline,
Erythromycin, TMP-SMX
Wound tissue, Right foot

TOTAL PATIENTS: 39
(+) E. faecalis moderate growth

Sensitive to Penicillin, Linezolid, Ampicillin, Vancomycin, Gentamicin
Intermediate to none
Resistant to none
06/03
Hgb 136 (141) Hct 0.40 (0.417) Plt 239 (236) WBC 12.10 (11.8) N
0.77 (0.88) L 0.20 (0.10) M 0.02 (0.02) E 0.01 (-), Na 138 (139.5) K
3.42 (3.04) CRP 201.14 Albumin 3.4
ESR 17
06/10/2024
WOUND CS, RIGHT FOOT
NO GROWTH AFTER 5 DAYS OF INCUBATION
06/11/2024
Vancomycin Trough Level 8.40 (5.00-10.00) Crea 0.68 eGFR 107
210E Omeprazole 40mg/IV Q12H 06/20 06/20 Awaiting:

RAVASCO, Jill Manalac Losartan 50mg/tab OD Urinalysis CXR -12L ECG
51/F Dark yellow sl. turbid pH 5.0 SG 1.010 Albumin 2+ Sugar (-) Suspicious infiltrates are seen in the upper lung areas. -CBC PC, Na, K, Crea, BUN, UA
Leukocyte (-) Erythocyte (-) Bilirubin + Nitrite (-) Ketone (-) Interstitial densities are noted in both perihilar and lower lung areas -CXR
Main Service: GI with suspicious faint nodularities appreciated in the lower lungs -PT INR
Urobilinogen normal RBC 0-1 Pus 1-3 Squamous ++ Transitional
Referrals: -HBA1C
Epithelial Cell + Bacteria + Mucus + Amorphous urates + Calcium Heart is enlarged
CV -SARS COVID RAT
Endo oxalate (-) Amorphous phosphate (-) Triple Phosphate (-) Hyaline 30 Diaphragm and both costophrenic sinuses are intact
Granular (-) Waxy (-) RBC Cast (-) WBC cast (-) There is slight scoliosis of the thoracic spin , Pending:
Assessment: IMPRESSION: -MGH (6/23)
LGIB R/O Malignancy BUN 19 Na 124 (L) K 4.1 Crea 0.87 eGFR 81 HbA1c 7.36 (H) SUSPICIOUS UPPER LUNG INFILTRATES. TAKE
APICO-LORDOTIC VIEW.
PT 15.5, INR 1.3 CONSIDER INTERSTITIAL INFECTION IN BOTH LOWER LUNGS
WITH SUSPICIOUS PULMONARY NODULES APPRECIATED.
Hgb 52 (L) Hct 0.18 (L) Plt 565 (H) WBC 13.14 (H) N 0.77 (H) L 0.13 SUGGEST CORRELATION WITH CLINICAL FINDINGS, CT SCAN
(L) M 0.08 E 0.02 MAY BE THE APPROPRIATE STUDY TO BETTER
DEMONSTRATE THE CHANGES IN BOTH LUNG FIELDS
06/19
HGB 71L RBC 2.72L HCT 0.22L PLT 409H WBC 16H N 0.77H L
0.20L M 0.02 E 0.01
Na 136 K 4.63
PT 15.5 INR 1.3 PTR 1.3
BUN 19 Na 124L K 4.1 Crea 0.87 eGFR 81 HBA1C 7.36H

HGB 52L HCT 0.18 L RBC 2.24L WBC 13.14H PLT 565H L 0.13L M
0.08 E 0.02
211 A Amlodipine 5mg/tab 1 tab 05/23 Awaiting:

GUNIO, ERNESTO OD Pending: Chest CT Scan w/ Contrast (6/22)
68/M FeSO4 + PA tab 1 tab OD Hgb 93 (97) Hct 0.27 (0.29) Plt 415 (420) WBC 10.20 (14.30) N 0.77
Main Sevice: Nephro NaHCO3 650mg/tab 1 tab (0.77) Seg 0.77 (0.77) L 0.15 (0.21) (M 0.01) E 0.08 (0.01)
Referrals: TID
Na 140 (143) K 3.66 (3.93) Crea 2.63 (3.49) eGFR 26 (18)
Assessment: CKD Stage
3B Secondary to HTN
TOTAL PATIENTS: 39
Nephrosclerosis
211B 06/24/2024 06/23/24 Awaiting:

CALISIN, Ziedrick CXR Portable Pending: Blood CS 2 sites (6/24); MRSA
30/M Coagulation Assay: PT 13.7 secs NC 11.5 secs PT ratio 1.1 INR 1.2 Lung fields are clear. Screening
Main service: Nephro APTT 36.9 secs BC 33.6 secs Heart is magnified.
Referrals: TCVS Diaphragm and both costophrenic sulci are intact.
Hepatitis Panel: IMPRESSION
Assessment: CKD St. 5 HBsAg 0.18 NONREACTIVE Magnified cardiac size.
sec to HTNSS Anti-HBc Total 7.46 REACTIVE
Anti-HBs 287.30 REACTIVE
Anti-HCV 0.04 NONREACTIVE
Crossmatching: ABO A positive, Compatible in 3 phases
06/23/2024
CBC
Hgb 61 (L) RBC 2.03 Hct 0.19 (L) Plt 189 WBC 9.80 N 0.76 (H) L
0.21 M 0.02 E 0.01
6/23/24
BUN 120.80 (H) SGOT 17.40 SGPT 13.20 Na 131 (L) K 8.66 (H)
iPhos 13.95 (H) Mg 4.25 (H) iCa 1.01 (L) Crea 36.91 (H) eGFR 1
6/23/24
ABG
pH 7.3 pCO2 21.0 pO2 109.9 SO2 97.2 HCO3- 10.4 TCO2 11.1 BE
ecf -16.2 BEb -14.0 SBC 13.2 O2CT 7.3 O2CAP 7.2 A 119.4
A-aDO2 9.5 a/A 0.9 RI 0.1 PO2/FIO2 523.2
Desired FIO2 11.46
211B Omeprazole 07/01/24 07/02/24 Awaiting:

BALBALOSA, Elias Ciprofolxacin CBC HGB 74 HCT 0.25 PLT 584 x10^9 WBC 7.70 x10^9 Initial CXR finding:
Main Service: Gastro Racecadotril Enlarged right thyroid
Referrals: CEA 0.73 Large hypoechoic structure probable thyroid cyst with intramural
Endocrinology Racecadot PTT 22.60
nodules measuring 4.1x2.6x4.7
Normal Isthmus
Assessment: Sigmoid
Adenocarcinoma ril Thymo Cystic nodule left lobe
211C 06/20 Awaiting:

CANLAS, Marlene CBC HGB 141 HCT 0.42 PLT 395 WBC 20 N 0.80 S 0.80 L 0.18 M -PT INR APTT
Ocampo 0.02 E 0
Pending:
Main Service: Med Onco SARS COVID RAT Negative -For Biopsy tom 7am
Referrals:
IR BUN 10.70 AST 46.30 (High) 88.10 (High) Na 134 (Low) K 3.69 Crea
Gyne onco 0.71 eGFR 107
Gastro
Uro
Assessment: Cervical
CA ST IB
211D Folic acid tab 1 tab BID 6/22/2024 06/15 Awaiting:

FRAYNA, John Louie E. Sideral sachet OD Na 140(138) K 3.43 (3.36) PORTABLE CXR - anti-dsDNA
30/M Subdexide 250 LSU BID Suspicious nodular densities are seen in the left upper lobe. - Ferritin, Bilirubin, Iron, TIBC, LDH, AST, ANA,
Methylprednisone 60mg/IV 06/21 The rest of the lung fields are clear.
Main Service: Hema OD Hgb 87, Hct 0.27, Plt 206, WBC 5.10, N 0.87, L 0.13. Heart is not enlarged. Pending:
Referrals: Omeprazole 40mg/IV OD Diaphragm and both costophrenic sulci are intact. - KUB UTZ
Rheuma Omeprazole 40mg/cap OD 06/19 IMPRESSION: - Urinoscopy
CV Entresto, 50mg/tab 1 tab PBS No abnormal WBC seen, RBCs: Hypochromic with anisocytosis SUSPICIOUS LEFT UPPER LUNG DENSITIES. SUGGEST - Serum albumin, UPCR
Nephro BID poikilocytosis, presence of nucleated RBC, platelets markedly APICO-LORDOTIC VIEW. -Repeat INR on 06/04
Empagliflozin 10mg/tab 1 decrease
Assessment: T/C Evan’s tab BID 06/11/24
TOTAL PATIENTS: 39
syndrome; Lupus; CaCO3 + Vit D3 1 tab BID 06/18 Lumbosacral Spine APL
Nephritic VS Nephrotic Methylprednisone 50g/tab 2 Coagulation Assay TECHNIQUE:
Syndrome tabs BID Lupus Coagulant 1 56.6 Lupus Coagulant 2 35.3 LA1/LA2 Ratio 1.6 AP and lateral views
Carvedilol 6.25mg/tab 1 tab
FINDINGS:
BID Coombs Test DIrect Negative
Enoxaparin 0.6 mg/cc BID Coombs Test Indirect Negative The lumbar lordosis is mildly straightened.
Aspirin 80mg/tab 1 tab in Autocontrol Negative Vertebral heights and disk spaces are maintained.
ODHydroxychloroquine Osteophyte formation is noted along the anterosuperior endplate of
20mg/tab OD Coagulation Assay L4.
Methylprednisolone 1g/IV PT 12.0 PTR 1.0 INR 1.0 aPTT 38.8 Pedicles are intact.
Negative for spondylolisthesis.
CBC
No abnormal soft tissue density or calcification identified.
Hgb 68 (L) RBC 2.25 (L) Hct 0.22 (L) PC 66 (L) WBC 5.20 Neu
IMPRESSION:
0.84 (H) Lym 0.14 (L) Eos 0.02
Mild lumbar spine straightening, may relate to muscle spasm
No compression deformity or spondylolisthesis
Retic Count 215
L4 osteophyte formation, may relate to intercalary bone verus limbus
06/17
Anti-dSDNA: 1201.14 (Strong Positive) vertebrae
Albumin 2.0 (L)
06/16 06/08/24
WAB UTZ
Total protein 163.40 HIGH Crea 72.28 P/Crea ratio 2.26 IMPRESSION:
MODERATE FATTY INFILTRATION OF THE LIVER
06/15 LEFT RENAL CYST
UNREMARKABLE STUDIES OF THE VISUALIZED PANCREAS,
Yellow, sl turbid, 6.0, 1.005, albumin 3+, sugar neg, leu pos, ery pos,
bilirubin neg, rbc 20-25, pus 2-6, bacteria +, mucus + GALLBLADDER, RIGHT KIDNEY, SPLEEN, PROSTATE GLAND
AND URINARY BLADDER
BUN 23.60 (H), Na 135 (L), K 3.99, Crea 1.09, eGFR 94
211E Losartan 50mg/tab OD 7/1

PARAGAS, Orlando Pantroprazole 40mg/IV OD
69/M HNBB 20mg/IV Q8
Main Service:
Referral: Endo
Assessment:
Hypertension stage 2,
Controlled DMT2, AKI w/
CKD, Hypoalbuminemia,
GERD,
212A Piperacillin Tazobactam 06/20 06/14 Awaiting:

CIEGO, Reynaldo 2.25g/IV Q6H Na 123L K 3.56 KUB UTZ
85/M NAC 600mg/tab 1 tab in ½ IMPRESSION: Pending:
glass of water NORMAL SIZED RIGHT KIDNEY AND SMALL SIZED LEFT -ETA GSCS
HGB 118 RBC 4 HCT 0.35 PLT 275 WBC 11.20 N 0.68 L 0.25 M
Amlodipine 5mg/tab OD
Main Service: Pulmo 0.02 E 0.05 KIDNEY WITH DIFFUSE PARENCHYMAL CHANGES.
Telmisartan 40mg/tab
Referral: CV, Nephro Ketoanalogue + Essential RENAL CORTICAL CYSTS, BILATERAL
Amino Acid OD 06/19
Assessment: Azithromycin 500mg/tab Na 125L K 3.90
q24h 06/11
CAP-MR, PTB
Febuxostat 40mg/tab OD PORTABLE CHEST
06/17
Meropenem 1g/IV Q12H Ill-defined densities are seen on both upper lung fields.
Ophthalmology ABG
Omeprazole 40mg/IV The heart is not enlarged.
Assessment: Vitamin B Complex 1 tab Aorta is tortuous and calcified.
Immature Cataracts, OU; OD Diaphragm and costophrenic sulci are intact.
Grade I Hypertensive Carvedilol 12.5mg/tab BID
IMPRESSION:
Retinopathy, OU; No (Amlodipine Increased
from 5mg/tab to 10mg/tab TO CONSIDER PTB, BOTH UPPER LUNG FIELDS, PRESENCE
signs of TB Chorioretinitis,
on 06/16/24) OF CONCOMITANT PNEUMONIA CANNOT BE TOTALLY RULED
OU
● Amlodipine OUT.
TOTAL PATIENTS: 39
10mg/tab 1 pH 7.47 pCO2 34.10 pO2 73.60 HCO3 25.10 FiO2 21% O2 Sat ATHEROMATOUS AORTA.
tab OD 95.50% BE 2.30 RR 22 pf ratio 350.48 dFiO2 22.31% aAO2 0.69 a-A
(HOLD as of 06/16/24) gradient 33.51
● Telmisartan Interpretation:
40mg/tab 1 Uncompensated RespiratoryAlkalosis with Normal Oxygenation On
tab OD Room Air (by AGE)
HRZE 3 tabs 30 mins
pre-BF, OD Na 129 (L) K 4.40
Atorvastatin 20mg/tab 1 tab
ODHS 06/16
Carvedilol 12.5mg/tab BID Examination: Culture and Sensitivity
Risperidone 1mg/tab ½ tab
>No growth after 5 days of incubation
PRN
Rabeprazole 20mg/tab 1
tab OD Hgb 108 RBC 3.65 Hct 0.32 PC 211 WBC 14.5 (H) Neu 0.8 (H) Lym
Paracetamol 500mg/tab 1 0.17 (L) Mon 0.02 Eos 0.01
tab in 3 days Q6 PRN
Tramadol 50mg/IV for Mod FT3 1.44L FT4 1.22 TSH 0.12L
to severe pain Q6
Ketorolac 30mg/IV for 1 day
BUN 22.80 Na 135 K 2.95L Mg 1.93 iCa 1.28 Crea 1.43H eGFR 48L
Q6
Celecoxib 200mg/cap for 3
days Q6 Blood with ARD, left arm CS: no growth after 5 days of incubation
Oral care with Procalcitonin 0.09L

Chlorhexidine TID
Salbutamol 1 neb + 2cc pH 7.526 pCO2 34.0 HCO3 28.4
PNSS q8
CBG monitoring q12
pH 7.497 pCO2 33.8 HCO3 26.4
Salinase nasal spray 12
grams R side TID 06/14
Oxynetazoline nasal spray Sputum MTB:
(2 sprays right) PRN MTB Detected
Optive fusion QID
RIF Resistance not detected
06/11
Procal 0.09L
Uric Acid 9.60 (H) Inorg PO4 3.13 Mg 2.19 iCa
1.30 Albumin 2.6 (L)
BUN 29.40H AST 30 ALR 13.10 Na 133L K
3.85 Crea 1.67H eGFR 40
Hgb 108 (L) RBC 3.59 (L) Hct 0.32 (L) MCV 87.70, MCH 30 MCHC
34.20 RDW 14.60 MPV 6.80 Platelet 256 WBC 8.30 Neutro 0.68
Segmenters 0.68 (H), Lymph 0.29 Mono 0.02 (L), Eos 0.01 (L)
Basophils -
212A LUSUNG, Nelia Piperacillin Tazobactam 06/22

4.5g/IV in 90 cc PNSS 6/22: Hgb 127 Hct 0.38 Plt 206 WBC 20.40 N 0.89 S 0.89 L 0.08 M Awaiting:
Main: ID 0.03 Pending:
Sitagliptin 100mg/tab 1 tab
Referrals:
OD
Neuro 6/22: BUN 15.80 UA 5.50 Na 132 (L) K 3.94 IPhos 2.22 (L) Ica 1.20
HBA1C 7.30 (H) Crea 1.05(H) eGFR 56
Assessment: Cellulitis
Right Leg; HTN; DM type
2 ; t/c Encephalopathy sec
to 1) Infection 2.
Electrolyte vs. metabolic
derangement
TOTAL PATIENTS: 39
SURGICAL COMPLEX (0M; 19R)
217D Mannitol 150 cc/IV q4 06/22/24 Pending:

MAGLALANG, Florencia Omeprazole 40mg/IV OD Blood Chemistry Na K iCa Mg
60/F Dexamethasone 5mg/IV q6 Na 136 (136) K 3.74 (2.99) (L) 12L ECG
Paracetamol 600mg/IV q8 AV Duplex
Main: NSx Ketorolac 30mg/IV q8 06/16 Craniat CT scan
Referrals: CV Betahistine 24mg/tab 1 tab PT 11 PTT 25.9 INR 0.9 JP removal AM 6/23
TID
Hgb 124 RBC 4.17 Hct 0.37 PC 224 WBC 11.70 Seg 0.89 Lym 0.09
CBG monitoring TIDACHS Mon 0.02
ABO Typing “O” Positive

Ab Screening Negative
217E Azithromycin 250mg/5ml 06/19 KUB UTZ (06/16/24) Awaiting:

MONFERO, Benita OD Na 133L K 4.32 The right kidney measures 9.2 x 4.5 cm (L x W) with a parenchymal - 2D Echo wih DS
86/F Pantoprazole 40mg/IV, OD thickness of 1.9 cm. It exhibits increased parenchymal echogenicity.
pre breakfast 06/16/24 No evident solid nor cystic mass lesion is appreciated. Negative for Pending:
Main Service: Neuro Citicoline 1g/IV q12h Examination : Culture and Sensitivity lithiasis. The pelvocalyceal complex is dilated. - Urine GS/CS
Referrals: Piperacillin-Tazobactam >No growth after 2 days of incubation The left kidney measures 9.0 x 4.9 cm (L x W) with a parenchymal
Anes 2.25g/IV in 50cc PNSS to thickness of 1.8 cm. It likewise exhibits increased parenchymal
CV run for 1-2 hours every 6 06/15/24 echogenicity. No evident solid nor cystic mass lesion is appreciated.
Endo hours HgB 90 (97) RBC 3.15 (3.46) HCT 0.27 (0.29) MCV 83.90 MCH Negative for lithiasis. The pelvocalyceal complex is not dilated.
Nephro Aspirin 80mg/tab 1 tab OD 28.50 MCHC 34.0 RDW 15.0 MPV 7.50 PLT 359 (352) WBC 3.80 The urinary bladder is distended with a pre-void volume of
GS Rosuvastatin 10mg/tab 1 approximately 311.9 cc. Intravesical low level echoes without
(12.20) N 0.42 S 0.42 L 0.52 M 0.03 E 0.03
tab ODHS posterior acoustic shadowing are seen in the dependent portion. The
Assessment: KCl syrup 20 mEq TID for 6 wall is not thickened measuring 0.3 cm. Post-void sonogram shows
Encephalopathy 2 to multi doses 06/11 about 202.4 cc of residual urine.
factorial causes t/c Major Insulin glargine (Toujeo) 10 Light yellow Turbid pH 8.0 SG 1.010 Alb 1+ Sugar/Bili/Nitrite/Ketone IMPRESSION:
Neurocognitive DO units/sc OD 8PM Neg Leuko/Erythro Pos Urobili Normal RBC 10-20 WBC over 100 NORMAL SIZED KIDNEYS WITH DIFFUSE PARENCHYMAL
Insulin glulisine (Apidra) 6 (-) Yeast (+) Squamous (-) Renal (-) Transitional (+++) Bacteria (-) CHANGES. SUGGEST CORRELATION WITH SERUM BUN AND
MGH units/sc q4hours pre Mucus Thread (+) Amorphous urates (-) Uric acid/CaOx/Amorphous CREATININE.,
feeding phosphate/Triple phosphate (-) Hyaline/Granular/Waxy/RBC/WBC GRADE Il- |I HYDRONEPHROSIS, RIGHT.
Omeprazole 40mg/tab OD cast MARKED URINARY RETENTION OF ABOUT 64% WITH
Amlodipine 10mg/tab OD INTRAVESICAL SEDIMENTS AND/OR CELLULAR DEBRIS.
Risperidone 2mg/tab PRN Comparison 6/11 vs 6/5
Memantine 10mg/tab Hgb 97 (110) RBC 3.46 (3.90) Hct 0.29 (0.32) MCV 83 (82.90) MCH
ODHS 28.20 (28.30) MCHC 34 (34.10) PC 352 (332) WBC 12.20 (17.30)
Lactulose 30mL ODHS Seg 0.67 (0.89) L 0.29 (0.10) M 0.02 (0.01) E 0.02 (0.00)
Bethametasone 25mg/tab 1
tab OD Na 137 K 3.79
Betanechol 25mg/tab
Memantine 10 mg/tab 06/10
Sitagliptin 100mg/tab OD Culture & Sensitivity Bactec Fx (Aerobic): Final Report- No growth
AM after 5 days incubation
KCl 20 meqs syrup OD
Sitagliptin + Metformin 06/09
100/1000mg/tab OD Na 141( 146) K 2.77(2.68)
06/05/2024
HS Trop I 0.1138
Hgb 110 RBC 3.90 Hct 0.39 MCV 82.90 MCH 28.30 MCHC 34.10
RDW 7.50 Plt Ct 332 WBC 17.30 N 0.89 L 0.10 M 0.01
ABG: pH 7.479 pCO2 47.1 pO2 67.2 sO2% 93.9 Hct 34 Hb 11.3
pCO2tc 47.1 pO2tc 67.2 HCO3 35.3 BEecf 11.5 BEb 11.1 SBC 34.7
O2Ct 14.9 O2Cap 15.7 A 192.9 a/A 0.3 PO2/FIO2 186.6
06/05/2024
Digoxin Assay: 1.12 ng/mL (0.8-2.0)
HS Trop I: 0.956 BUN 13.10 AST 12.7 ALT 12.6 Sodium 141.0
TOTAL PATIENTS: 39
Potassium 3.17(L) ionized Calcium: 1.23 HBA1c: 11.57% Creatinine

0.78 eGFR 74
Urinalysis: Yellow Turbid 7.0 1.010 Albumin 2+ Sugar 4+ Leukocytes
POSITIVE Erythrocytes POSITIVE Ketone POSITIVE RBC 12-20
Pus cells Over 100
Squamous Cell: + Transitional Epithelial Cell FEW Bacteria ++++ No
dysmorphic RBC seen
ABG: pH 7.476 pCO2 42.7 pO2 282.7 sO2% 99.7 Hct 26 Hb 8.6
pCO2tc 42.7 pO2tc 282.7 HCO3 37.8 BEecf 8.0 BEb 8.2 SBC 32.0
O2Ct 12.8 O2Cap 12.0 A 170.4 a/A 1.7 PO2/FIO2 883.5
06/08/24
Cholesterol 89 Triglycerides 105.40 HDL 23.50 LDL 39.70 N 146 K
2.68 Cl 106.10 Albumin 2.0
06/09
Na 141 K 2.77
219A Cefoxitin 2g/IV 06/16/24 05/03/24 Awaiting:

CAPARAS Atorvastatin 80mg/tab Hgb 105 RBC 3.5 Hct 0.31 Plt 180 WBC 9.5 (L) N 0.75 L 0.2 M 0.02 CXR -
Trimetazidine 35mg//tab E 0.03 Atheromatous aorta
Metoprolol 50mg/tab Pending:
Degenerative osseous changes
Main Service: TCVS Sinecod forte tab/ tab 5:51AM Na 142 K 2.87 (L) iCa 1.11 (L) -
Referrals: Apidra COrrection Scale 1:32PM Na 139 K 2.99 (L) iCa 1.09 (L)
CV Ondansetron 4mg/IV for 05/06/24
Anes PONV 06/15 WAB UTZ
Pulmo Paracetamol 1g/IV while on Liver: Hepatic steatosis. Consider focal fatty sparing versus true
Blood CS L&R arm: No growth after 5 days of incubation
Endo NPO hepatic nodules. A triphasic CT may be done for further assessment.
GI Toujeo 10 units/sc Non-dilated ducts
Salbutamol + Ipratropium 06/13/24 3:01AM
Total Protein 4.47L (4.70) Albumin 2.62L (2.65) Globulin 1.85 (2.05) GB: Cholecystolithiases with no signs of acute inflammation
Assessment: Neb
Infrarenal Abdominal Spiolto 2 pufss OD A/G Ratio 1.42 (1.29) Na 146H (142) K 4.27 (4.27) Mg 2.09 (2.11) Pancreas, spleen: No pancreatic and splenic pathology detected
Aortic Aneurysm; ASHD Atorvastatin 40mg/tab iCa 1.05L (1.12) Crea 2.26H (3.14) eGFR 33 (22) sonographically
CAD, HTN Stage 2; Lactulose 30 cc Upper abd aorta: Consider fusiform aneurysm of the infrarenal
COPD probable not in Empaglifozin+Linagliptin abdominal aorta with thickened walls. An aortogram may be done for
CBC Hgb 141 (83) RBC 4.76 (2.79) Hct 0.42 (0.24) Plt 179 (204)
acute exacerbation 25/5mg OD further assessment
WBC 14.60H (14.90) Neu 0.87H (0.84) Lym 0.12 (0.14) Mon 0.01
(0.02) Kidneys: Consider right renal angiomyolipoma. Unremarkable left
s/p Open surgical repair of
pH 7.457 (7.336) pCO2 33.9 (46.9) pO2 255.6 (88) HCO3 24.2 kidney
infrarenal Abdominal
Aortic Aneurysm (25.1) Urinary bladder: urinary retention
(06/10/2024); s/p On table Prostate gland: enlarged prostate gland
angiography (06/11/2024); 06/12/24
s/p Revision of Neoaorta 05/18/2024
PT 14.9sec APTT 72.5secH INR 1.3
(Aortofemoral CAROTID DUPLEX SCAN
Reconstruction, Right)
06/11 Impression: Carotid artery disease; <50% stenosis, bilateral internal
MGH Na 144 K 4.55 carotid arteries (approx. 1-15%); Normal antegrade flow, bilateral
vertebral arteries
pH 7.438 pCO2 36.5 pO2 170.6 HCO3 25.0 a/A 0.7
05/13/2024
PTT 709.3 NC 32.4 2D-ECHO w/ DS
Normal left ventricular dimension by body surface area with normal
ABG left ventricular mass index of 108 g/m2 and relative wall thickness of
pH 7.389 Pco2 31.7 pO2 79 HCO 19.1 0.39 with good wall motion and contractility.
Normal right ventricular dimension with adequate wall motion and
06/10 contractility.
CBC Hgc 127 hct 0.38 plt 203 wbc 21.2 Neu 0.81 Eos - lym 0.15 Normal right and left atrial dimensions by body surface area with
mono 0.04 normal left atrial volume index of 13 ml/m2 and with no evidence of
thrombus.
PT 12.7 NC 12.4 aPTT 33.8 INR 1.1 Thickened anterior mitral valve leaflet without restriction of motion.
Structurally normal aortic, tricuspid, and pulmonic valves.
Na 139 K 4.31 iCa 1.15 Crea 1.12 eGFR 76 Normal main pulmonary artery.
Normal aortic root diameter.
TOTAL PATIENTS: 39
Hgb 127 RBC 4.19 Hct 0.38 PC 203 WBC 21.20 Neu No pericardial effusion.
0.81Band0.06Seg0.75 Lym 0.15 Mon 0.04 DOPPLER
Mosaic color flow display across the mitral and tricuspid valves
pH 7.352 pCO2 42.5 pO2 265.7 HCO3 23.8 a/A 0.7 during systole.
Reversed mitral inflow pattern and abnormal mitral annular velocity
06/09 by tissue Doppler imaging.
CBC Normal pulmonary artery pressure of 14 mmg by Pulmonary
Hgb 143 RBC 4.58 Hct 0.42 MCV 91.20 MCH 31.20 MCHC 34.20 acceleration time.
RDW 14.00 MPV 7.70 PLT 209 WBC 5.30 Neut 0.49 Lymphocytes CONCLUSION
0.44 Monocytes 0.03 Eosinophils 0.04 Normal left ventricular geometry by body surface area with adequate
contractility, resting systolic function, and doppler evidence of
Blood Chem impaired relaxation.
Na 140 K 3.70 Crea 0.93 eGFR 95 Mg 2.33 iCa 1.26 HBA1C 8.16% Mitral regurgitation, mild.
AST 24.40 ALT 36.40 Tricuspid regurgitation, mild.
Grade 1 left ventricular diastolic dysfunction
PROTHROMBIN TIME 12.3
NORMAL CONTROL 12.2 05/16/2024
PROTHROMBIN RATIO 1.0 Upper Abdominal CT scan
INTERNATIONAL NORMALIZED RATIO 1.0 Findings: There is fusiform aneurysmal dilatation of the infrarenal
abdominal aorta, spanning the L2-L4 vertebral levels, with an
HIGH SENSITIVE TROPININ-I 0.0136 approximate involved length of 9.9cm. It measures 5.8 x 4.7cm (W x
AP) in its widest dimension. Intramural mural thrombus formation is
HBsAg 0.67 NONREACTIVE also observed, with a maximum thickness of 3.3cm and an effective
Anti-Hbc Total 9.58 REACTIVE luminal diameter of 2.2 x 1.6cm. The partially-visualized right
HBeAg 0.38 NONREACTIVE common iliac artery also appears dilated measuring 2.7 x 2.7cm.
Anti-HBS 5.78 NONREACTIVE Calcified and noncalcified mural plaques line the abdominal aorta
and its branches.
Na 138 K 4.22 Albumin 3.8 Impression: Atherosclerotic vessel disease with infrarenal abdominal
aorta with mural thrombus formation and right common iliac artery
pH 7.469 pCO2 35.61 pO2 80.5 HCO3 26.1 a/A 0.8 aneurysm
06/08
ABO Typing “AB” Positive
Ab Screening NEGATIVE
Na 140 K 3.7 Crea 0.93 eGFR 95
Mg 2.33 iCa 1.26 HbA1c 8.16
High Trop I 0.0136
05/03/24
CBC Hgb 133 Hct 0.38 RBC 4.15 MCV 92.5 MCH 32 MCHC 34.6
RDW 12.5 Plt 213 WBC 9.29 M 68.6 L 20.9 M 8.3 E 1.4 B 0.8
BLOOD CHEM FBS 181.28 Cholesterol 193 Trig 150.45 HDL 27.41
LDL 135.52 VLDL 30 Chol/HDL ratio 7.04 BUN 11.4 Crea 0.9 Uric
acid 5.49 Na 139 K 4.29 Cl 101.7
UA Yellow clear SG 1.020 pH 6 RBC 1-3 WBC 1-2 Bacteria few

Mucus threads few
TOTAL PATIENTS: 39
219C GUTIERREZ Forgram 2g/IV (On call to 06/16 Pending:

OR) pH 7.391 pCO2 39.9 pO2 94.9 SO2% 97.2 Hct 38 Hb 12.8 -For urine CS
Main: Surgery Esoget 40mg/IV OD once -CBC PC, Na, L Crea (6/21)
Referrals: on npo
CBC
Nephro Paracetamol 500mg/tab
Anes Q6H Hgb 132 Hct 0.40 RBC 4.61 MCV 85.70 MCH 28.50 MCHC 33.30
Omeprazole 40mg/IV OD RDW 13.90 MPV 6.60 Plt 524 WBC 10.70 N 0.67 L 0.27 M 0.02 E
Assessment: Ondasetron 4mg/IV 0.04
Obstructive Nephropathy Forgram 1g/IV
sec to UPJO R/O Uretral UA
Atresia, R Yellow turbid pH 8.0 Sp. Gr. 1.020 Albumin 1+ Sugar (-) Leukocytes
(+) Erythrocytes (+) Bilirubin (-) Nitrite (-) Ketone (-) Urobilinogen
(normal) RBC 3-6 Pus Cell over 100 Yeast cell (-) Squamous cell (+)
Renal cell (-) Transitional Epithelial Cell (-) Bacteria (++++)
S/P TAKEDOWN OF
Amorphous Phosphate (++++) Triple Phosphate (+)
VESICOSTOMY, ILEAL
HARVEST,
Blood Chem
AUGMENTATION ILEO
Na 138 K 4.49 Inorganic Phosphate 3.13 iCa 1.30 Crea 2.68 (High)
CYSTOPLASTY
eGFR 33
(MACEDO) TECHNIQUE
219E IRESARE Pending: Repeat UA on D5 Antibiotics (6/23)

Main: Urosurg
Referral: CV
Assessment:
Benign Prostatic
Enlargement
220B DEQUILLA Enoxaparin 0.4mL/SC OD 06/22/24 05/01/2024 Awaiting:

Paracetamol 500mg/tab 2 Specimen: Proximal bone CS - Bacterial GSCS (aerobic and anaerobic of
Main: Ortho, Endo tabs for 3 days Q8 Final Report: No growth after 3 days incubation CXR: Essentially normal chest findings proximal bone)
Referrals: Tramadol 50mg/IV PRN - Fungal stain and CS of proximal bone
Hema Ondansetron 4mg/IV PRIN - AFB stain, MTB genexpert, mycobacterial CS
CV Pregabalin 75mg cap, cap 06/20 X-RAY L foot and ankle Pending: Blood CS 2 sites (6/23)
ID ODHS Na 137 K 3.31L Crea 0.72 eGFR 102
Anes Celecoxib 200mg/cap for 3 HGB 81L RBC 2.79L HCT 0.25L PLT 381 WBC 13.50H N 0.76 L LEFT FOOT AND ANKLE
days BID 0.21 M 0.01 E 0.02 There is non-visualization of the distal 1/4 of the 3rd, 4th and 5th
A> Diabetic foot, left KCl tab for 6 doses TID metatarsals of the left foot, as well as the related distal osseous
(Wagner 4) TMP-SMX 160mg/50mg/tab 06/19 structures
(-) MRSA, Sensitive for TMP-SMX, Minocycline, Levofloxacin, No There are Iytic changes involving the distal aspects of the visualized
Levofloxacin 750mg/tab
Q24H Microorganisms on GS of Proximal Bone 3rd-5th metatarsals with surrounding soft tissue swelling
Plantar and dorsal calcaneal spurs are noted.
CBG monitoring, TIDACHS 06/18
Toujeo 20u/SC PT 13.9 PTT 34.9 INR 1.2
VTL 9.60
06/17
pH 7.53 pCO2 34.40 pO2 71.40 HCO3 29.20 FiO2 21% O2 Sat
95.60% BE 6.80 RR 18 pf ratio 340.00 dFiO2 22.80% aAO2 0.67 a-A
gradient 35.33
06/16
Ab screening: Positive06/19
ABO Typing “A” Positive
ESR >150H
TOTAL PATIENTS: 39
Urinalysis Light yellow Slightly turbid pH 7.0 SG 1.010 Alb 1+ Sugar

2+ Leukocyte + RBC 0-3/hpf Pus 2-4/hpf SEC ++ Bacteria +
Hgb 77L RBC 2.86L Hct 0.24L PC 514 WBC 16.70H Neu 0.80 Lym
0.16 Mon 0.01 Eos 0.03
Chole 154 Tig 226H HDL 26.50L LDL 78 Na 132 K 4.08 HSCRP
248.25H Alb 1.8L Crea 0.83 eGFR 85
HbA1c 6.21%
06/11
PT 14.40 INR 1.25 PTT 59.40
220F Esoget 40mg/IV 06/19 Pending:

TUDLASAN, Marecel Buscopan 20mg/IV Na 139 K 3.63 Crea 0.80 eGFR 94
42/F Forgram 1g/IV
Tramadiol 50mg/IV PT 11.6 PTR 1.0 INR 1.0 APTT 40.1
Main Service: GS
Referral: CV HGB 125 RBC 5.10 HCT 0.38 PLT 318 WBC 7.20 N 0.58 L 0.37 M
0.02 E 0.03
Assessment:
Acute cholecystitis
MGH
220G 6/22
MENDOZA, Viola Hgb 105 (106), RBC 3.96, Hct 0.32 (0.33), MCV 81.70 (81.60), MCH Awaiting: Contrast Enhanced Cranial CT scan
56/F (26.50), MCHC 32.40 (32.50), RDW 16.80, MPV (7.10), PLT 281 (6/22)
(212), WBC 4.20 (4.20), Neutrophils 0.52 (0.59), Segmenters 0.52,
Main Service: OB Lymphocytes 0.44, Monocytes (0.04)
Referral: CV
6/22
Assessment: Sodium 137 (138) Potassium 3.42 (3.35) ionized Calcium 1.23
G1P0(0010) Endometrial Creatinine 0.43 (0.43) eGFR 113 (114)
CA Stage IVB
(Supraclavicular and
Axillary LN involvement,
consider uremia
221A Balallo 06/18 Pending: CT guided Biopsy

Hgb 131 Hct 0.38 (L) Plt 383 WBC 10.7 N 0.59 L 0.38 M 0.02 E
0.01
221C 06/05 Awaiting:

HIDALGO, Januario KUB: - Na, K, Crea
Both kidneys are normal in size and echopattern - CBC PC
Main Service: GS The right kidney measures 11.4 x 4.45 x 4.18 cms. With cortical - PT, PTT, INR
Referrals: CV thickness of 1.23cm. While the kidney measures 9.56 x 4.21 x 4.46 - Chest Xray
cms. With cortical thickness of 1.37cm. There is a 4.6 x 4.4 cm cystic - 12L ECG
A> Inguinal Hernia, Left; structure seen at the right kidney. The urinary bladder is fully
Hypertension Stage 2 distended. Prevoid 229.95mL. Postvoiding shows 9.91mL of residual
urine. Negative for intravesical mass.
MGH
IMPRESSION:
RENAL CORTICAL CYST, RIGHT
LEFT KIDNEY AND URINARY BLADDER, NEGATIVE
PSA: 1.62 ng/mL

TOTAL PATIENTS: 39
Prostate Ultrasound: Prostate gland is normal in size measuring 3.4

x 3.8 x 2.3 cm. With estimated weight of 16.76 grams. No
concretions noted, Normal sized prostate.
04/20
Chest PA
IMPRESSION: ATHEROSCLEROTIC AORTA. THORACIC
OSTEOPHYTOSIS.
04/19
Focused sonogram of the inguinal regions
Focused sonogram of both inguinal regions show a discontinuity at
the left inguinal wall region measuring about 2.3 cm in the widest
transverse diameter. There is herniation of omental fat and intestinal
loops through the aforementioned defect. The herniated portion does
not extend into the scrotum. There is no evidence of hernia in the
right inguinal region.
IMPRESSION: CONSIDER LEFT INGUINAL HERNIA AS
DESCRIBED.
221D Pending: MDM (6/24); Chest CT w/ Contrast

VICENTE (6/22)
MAIN SERVICE: OB
REFERRAL:CV,
Neurology
Assessment: Pancreatic
Head Mass; Well
Differentiated Pancreatic
NET s/p EUS Biopsy
(4/3/24)
221F Paracetamol 300mg/IV 06/20 Awaiting:

RAMOS, Ronald Q6H RTC TC 196.50 TG 194.30H HDL 22L LDL 131.40 -AST, ALT
48/M Ciprofloxacin 40mg/IV -12L ECG
Main: ENT Insulin gargline 100u/SC -CT Scan
Referral: OD
Endo Vidagliptin 50mg/tab BID 06/19/24
Amlodipine 10mg/tab OD HGB 154 RBC 4.80 HCT 0.46 PLT 217 WBC 16.80 N 0.86 L 0.12 M Pending:
Paracetamol 300mg/IV 0.02 -2D echo with DS
Q4H
Na 129L K 4.36 HBA1C 11.76H Crea 0.54L eGFR 123
222D Paracetamol 500 mg/tab 06/16/24 Awaiting:

PADUA Enoxaparin 0.5 cc Q12H Crossmatch - B positive -Blood CS X 2 Sites
Pregabalin 5mg/cap Q8H
Main: Gyne Paracetamol 300 mg/IV
6/15/24
Referral: Pulmo, GI, Diphenhydramine 25 mg/IV Pending:
TCVS Enoxaparin 0.2cc/SC OD Hgb 59 RBC 1.85 HCT 0.17 MCV 94.00 MCH 31.70 MCHC 33.70 -Possible transfer to PGH
RDW 16.30 MPV 7.50 PLT 295 WBC 2.70 N 0.71 S 0.66 L 0.22 M
G9P8 (8018) Cervical CA 0.04 E 0.03
stage IIB; Tumor
recurrence and 06/13/2024
progression s/p 3 cycles Procalcitonin 0.16 (L)
concurrent
chemoradiation with
cisplatin (2023) s/p 4 6/9/24
sessions of BUN 9.80 AST 94.60 ALT 10.20 Na 131 K 3.57 Mg 1.78 iCa 1.20
brachytherapy (2023) Crea 0.48 eGFR 124
s/p 4 cycles
chemotherapy with PT 13.2 NC 12.9 PR 1.1 INR 1.1 APTT 35.6 NC 35.4
carboplatin (last June 7,
2024)
pH 7.474 pCO2 39.3 pO2 87.6 SO2 97.0 Hct 28 Hb 9.4
Opt DAMA
TOTAL PATIENTS: 39
222E DEL ROSARIO Awaiting:

Main: Surgery Pending: CBC, Na, K, Crea, CXR (6/24)
Referral: Endo, CV
Assessment:
Multinodular Toxic Goiter
Clinically and
Biochemically Euthyroid
223C Cefuroxime 500mg/tab 1 06/16 Pending:

BARLISO, Jezebel tab q12h Troponin -
FeSO4 1 tab 30 mins
Main: Gyne premeals OD once on soft Awaiting:
06/15
Comanaged: CV diet - Chest Xray
Carvedilol 12.5mg/tab 1 tab AST 26.30 ALT 11.70 LDH 350H Crea 0.87 eGFR 7
Assessment: BID
Pulmonary Embolism, Atorvastatin 80mg/tab 1 tab
Myocardial Infarction OD
(NSTEMI) Omeprazole 40mg/tab 1 tab
OD
MGH Clopidogrel 75mg/tab 1 tab
OD
Aspirin 80mg/tab 1 tab OD
Enoxaparinn BID
223E Ampicillin 2g/IV for 48 hours 06/20 Pending: Still for home (6/22)
DANGANAN Methyldopa 250mg/tab 1 UA
tab q8 Y Sl. turbid pH 6.5 SpG 1.005 Erythocytes Positive Urobilinogen
Main: OB Aspirin 80mg/tab 2 tablets
Normal RBC 4-8 Pus Cell 0-3 Squamous Cell + Bacteria +
Referral: Endo Levemir 10 u/sc
Amlodipine 5mg/tab Amorphous Urates +
Assessment: Clindamycin 300mg/tab
G2P1 (1001 PU 28 weeks Paracetamol 500mg/tab
AOG PPROM X 1 hour Q4H 06/16
CHVD controlled CBC
Endo: Pregestational RDW 13.70 MPV 6.90 PLT 315 WBC 13.70 Neut (segs) 0.83
DMT2 Obese Class II, Lymphocytes 0.16 Monocytes 0.01
Metabolic syndrome
06/15
CBC
RDW 13.10 MPV 8.80 PLT 256 WBC 14.80 Neut (segs) 0.80
Lymphocytes 0.17 Monocytes 0.02 Eosinophils 0.01
226A Meropenem 2g/IV in 50mL 06/22/24 06/15 Awaiting:

SANTOS, Von PNSS q8 Crea 0.45 (0.79) Chest Xray Blood CS
Vancomycin 750mg/IV in Heart is magnified. Pending: CSF CS Studies (6/22), UA (6/22)
Main: NSx 90mL PNSS q12h 6/22/2024 Diaphragm and costophrenic sulci remains intact.
Referrals: Anes, ID Levofloxacin 750mg/tab tab Specimen: Blood w/ ARD, left arm CS An endotracheal tube is noted with its tip at the level of T3.
q24h Final report: No growth after 5 days incubation A NGT is again seen with its tip inadequately visualized.
Left Lateral Ventricular Levetiracetam 100mg/mL
Mass t/c Central syrup in 5mL 06/22/24
Neurocytoma s/p Paracetamol 500mg/tab 1 Urinalysis: Yellow, Turbid, pH 5.0, SC 1.020, Negative Albumin,
External Ventricular tab q4 PRN Negative Sugar, Positive Leukocytes, Negative Erythrocytes,
Drain Insertion, left Lactulose 30mL ODHS Negative Bilirubin, Negative Nitrite, Negative Ketone
Celecoxib 200mg/cap 1 cap RBC 0-1, Pus cell 6-13, Yeast ++++, Bacteria +, Mucus threads +
BID Presence of hyphal elements
Dexamethasone 4mg/tab 1
TOTAL PATIENTS: 39
tab q12h 06/19

NAC 600mg/effervescent Na 136
tab 1 tab NGT BID K 4.24
Levocetirizine +
Monteleukast ODHS 06/18
Urine GS: No microorganisms seen on both uncentrifuged and
centrifuged samples
CSF CS:
Culture: Acitenobacter baumannii
Sensitivity:
Sensitive to: Sulbactam-Ampicillin, Cefepime, Amikacin,
Ciprofloxacin, Minocycline, Piptazo, Imipenem, Gentamicin,
Levofloxacin, Ceftazidime, Meropenem, Tobramycin, TMP-SMX
Na 147 K 4.03
06/17
AST 119 ALT 317 Crea 0.48 eGFR 130
06/14
ABO RH “B” positive
226B Ondansetron 4mg/IV Q8 06/19 Awaiting:

DE GUZMAN, Eduardo PRN Hgb 108, RBC 3.22, Plt 466, - Bacterial GSCS
73/M Quetiapine 25mg/tab PRN Crea 0.83 eGFR 92
Duodart Tab ODHS Pending:
Main Service: ENT Esomeprazole 40mg/tab 06/17 - C. difficile Assay
Referrals: OD Na 135 K 4.90 Mg 2.37
ID Racecadotril 100mg/cap
Uro TID 06/16
GS Ceftazidime Avibactam Culture and Sensitivity Bactec FX (Aerobic)
Endo 2.5g/IV Q8 - No growth after 5 days incubation
CV Metronidazole 500mg/IV Q8 Culture and Sensitivity VITEK Automated
Paracetamol 600mg/IV Q6 - No growth after 5 days incubation
Assessment: PRN for pain
Laryngeal squamous cell Amikacin 1g/IV in 90cc BLOOD WITH ARD, Right Arm & Left Arm CS
carcinoma St. IV, S/P PNSS q24 Final Report: No growth after 5 days incubation
Tracheostomy followed by Atorvastatin 40mg/tab 1 tab
direct laryngoscopy with OD
biopsy followed by Meropenem 1gm/IV in 90cc 06/14
esophagoscopy PNSS for 1-2hrs q8 Na 138 K 3.00
(12/29/23); ASHD CAD Paracetamol 600mg/IV
HFpEF (EF 53) not in PRN 06/11
failure; s/p Laryngectomy Hydrocortisone 100mg/IV CBC
with rush frozen section for BT Hgb 107 RBC 3.28 Hct 0.32 MCV 96.70 MCH 232.80 MCHC 33.90
with lobectomy, left thyroid RDW 15.00 MPV 10.00 PLT 289 WBC 10.10 Neut (segs) 0.73
and modified radical neck Calmoseptine cream BID Lymphocytes 0.24 Monocytes 0.02 Eosinophil 0.01
dissection MEBO ointment
T2DM controlled (Hba1c White vinegar 10 mL PO ℅ Na 144 K 3.38 Crea 0.81 eGFR 93
6.9, egfr 95); SSi ENT during changes of
dressing 06/10
WOF: PEG swab Gram’s stain: No microorganisms seen, (+) Pus cells
Hypotension CBG monitoring OD Na 145 K 2.99 (L)
Apidra correction scale
181-230 2u/sc 06/8
231-280 4u/sc Na 143 K 2.84
281-330 6u/sc
>330 8u/sc Hgb 105 hct 0.33 pc 389 wbc 14.8 N84 L15 ‘1
06/06
6:41 AM
TOTAL PATIENTS: 39
Na - 150 mEq/L HIGH

K - 3.62 mEq/L
06/05
7:30 AM
Na - 153 mEq/L HIGH
K - 3.88 mEq/L
06/01
Specimen: Anterior neck devitalized tissue CS Culture: Enterobacter
cloacae Sensitive to: Amikacin, Intermediate to: None, Resistant to:
Ampicillin, Cefazolin, Cefotaxime, Ceftolozane-Tazobactam,
Imipenem, Co-Amoxyclav, Cefuroxime, Ceftazidime, Cefepime,
Meropenem, Piperacillin-Tazobactam, Cefoxitin, Ceftriaxone,
Aztreonam, Gentamicin, Tobramycin, Ciprofloxacin, Levofloxacin,
TMP-SMX, Ertapenem, Tetracycline
05/28
Vancomycin trough level 13.00
227A Omeprazole 40mg/tab OD 06/22/2024 6/5/24 Awaiting:

BARTOLO, Crispino Fluconazole 200mg/tab Hgb 123 Rbc 3.96 Plt 434 Wbc 9.80 N 0.73 Metamyelo 0.03 Bands PORTABLE CHEST - EMG-NCV (06/04)
55/M Q12 0.01 Segs 0.69 L 0.13 M 0.05 E 0.01 Myelo 0.08 Follow up examination when compared to previous study done last
Ceftriaxone 2g/IV in 90 cc 6/2/24 now shows elevated diaphragm with resultant crowding of Pending:
Main Service: Neuro PNSS to run for 1-2 hr q24 06/22/2024 basal lung markings. - 21 Channel EEG
Referrals: Lactulose 30 cc ODHS Na 120 (L) (127) K 4.66 (4.07) - Repeat TFTs after 6 weeks (07/15)
Endo Metronidazole 500 mg/IV to There is increased transverse diameter of the heart. - SFA, urinalysis
Pulmo run for 1-2 hr q6 6/22
- Perimetry, OCT-RFNL
CV Dexamethasone 5mg/IV q8 Both costophrenic sulci are intact.
ID NAC 600mg/tab aBid UA: Yellow sl turbid pH 5.0 sp 1.015 albumin neg sugar 3+ rbc 15-20 An nasogastric tube is seen with its tip not adequately visualized. -Repeat CBC PC, Na, K, ALT, AST tom
Ophtha - Signed out HRZE 4tabs OD pus 3-5 no crystals no cast no dysmorphic rbc seen -Possible Cataract OR EOR
ENT Vit B complex OD Desaturation episodes after lumbar tap procedure. -Repeat Na, K (6/23)
GI Metoclopramide 10mg/IV 06/11 - CSF Culture
Mannitol 100cc/IV Q8 No growth after 5 days incubation PORTABLE CHEST
Assessment: Telmisartan 800mg/tab OD Follow up examination when compared to previous done on
ARF sec to control Apidra correction scale: 06/10 - No new labs 05/06/2024 shows a amrkedly elevated right hemidiaphragm.
cause (CNS infection t/c 161-200 - 2u/sc Hazy densities are seen in the right perihilar region.
GBS) 201-240 4u/sc 06/08 The left lung remain clear.
>241 - 6u/sc CSF MTB GeneXpert: MTB not detected The heart size cannot be assessed.
Gurafenexin syrup IgG CSF 396.8 Aorta is atheromatous.
Methylprednisolone A nasogastric tube is seen with its tip at the gastric region.
16mg/tab BID 06/02 The left hemidiaphragm and both costophrenic sulci are intact.
CK total 57 Ther are no other findings of note.
CBG monitoring q12
(8am-8pm) 06/03 06/06
Apidra scale T3 1.27 (L), T4 0.86 (L), TSH 0.16 (L) PORTABLE CXR
Salbutamol + Ipratropium Follow up examination when compared to previous study done on
neb q8 6/05 June 5, 2024 now shows homogeneous density in the right lower
2:57PM lung field obliterating the right cardiac border, right hemidiaphragm
pH 7.457 pCO2 31.2 pO2 104.1 HCO3 22.2 A-aDO2 134.9 PF and right costophrenic sinus. This may relate to consolidation or
260.3 dfio2 23.1 pleural effusion.
Suggest sonographic correlation.
6:14PM Hazy densities are seen in the right perihilar region.
pH 7.469 pCO2 29.4 pO2 60.1 HCO3 21.5 A-aDO2 459.3 PF The left lung remain clear.
75.1 dfio2 79.87 Heart size cannot be properly assessed.
Aorta is now more prominent.
9:32PM The left hemidiaphragm and both costophrenic sulci are intact.
pH 7.463 pCO2 27.8 pO2 92 HCO3 20.1 A-aDO2 569.1 PF 92 A nasogastric tube is seen with its tip at the gastric region.
dfio2 65.22
CT SCAN
Clinical Summary: Bilateral lower extremity weakness
06/07 Examination: Contrast-enhanced Cranial CT Scan
ENZYME IMMUNOASSAY Technique: Non-contrast and Contrast-enhanced Cranial CT Scan
Specimen: CSF was performed following standard section protocol.
HSV IgG - 1.90 Reactive Findings:
HSV I IgM - 0.03 Non-Reactive No abnormal enhancing intra-axial and extra-axial lesion seen.
TOTAL PATIENTS: 39
HSV II IgG - 0.65 Non-Reactive A hypodense area is noted in the left external capsule.
There is mild symmetric widening of the cerebral cortical sulci, both
RPG 110.4 Sylvian fissures and basal cisterns as well as the cerebellar
Serum IgG 11.53 Alb 3.1 (L) interfolial spaces with prominence of the third and fourth ventricles.
CSF Total protein 197 (H) Both lateral ventricles are not dilated with mild asymmetry seen (may
CSF Glucose 47.7 still be a normal variant). Cavum septum pellucidum is appreciated.
No shift of the midline structures.
Blood CS, Left and Right Arm - Aerobic Posterior fossa structures are normal.
No growth after 5 days incubation The right frontal sinus is hypoplastic. There is mucosal thickening in
both ethmoid sinuses. Semicircumscribed opacities are noted in both
MENINGITIS/ENCEPHALITIS PANEL maxillary sinuses. The rest of the paranasal sinuses and mastoid air
S. pneumoniae, N. meningitidis, S. agalactiae, L. monocytogenes, H. cells are well-aerated. A nasogastric tube is seen coursing through
influenzae, E. coli K1, S. pyogenes, M. pneumoniae, EnterPovirus, tho left nostril.
HSV-1, HSV-2, Human parechovirus, HHV-6, VZV, C. neoformans - There is incidental finding of calcific focus in the right maxillary
NOT DETECTED region.
IMPRESSION:
NO EVIDENCE OF ABNORMAL INTRA-AXIAL NOR EXTRA-AXIAL
06/06 ENHANCEMENT
Procal 0.26 (L) CHRONIC INFARCT, LEFT EXTERNAL CAPSULE MILD
Cryptococcal Antigen (CALAS) Negative CEREBRO-CEREBELLAR ATROPHY
MUCOUS RETENTION CYSTS, BOTH MAXILLARY SINUSES
ABG 6/6 2:42AM INCIDENTAL FINDING OF ANON-SPECIFIC CALCIFICATION IN
pH 7.435 pCO2 33.6 pO2 184 HCO3 22.8 A-aDO2 331 PF 230 THE RIGHT MAXILLARY SOFT TISSUES
dfio2 26.09
06/10
AFB PORTABLE CXR
Specimen: CSF Follow-up examination when compared to study done on 6/6/24
No bacilli seen shows resolution of the previously noted homogenous density in the
right lower lung field.
GRAM’S STAIN - CSF - Negative There is interval regression of the hazy densities in the right perihilar
FUNGAL STAIN - CSF - Negative region.
INDIA INK - CSF - Negative The heart is not enlarged. (14.7/28.2)52%
Aorta is atheromatous.
BLOOD CHEM Diaphragm and costophrenic sulci are intact.
Na - 124 Nasogastric tube is seen with its inferior tip inadequately visualized.
K - 4.49
Albumin - 2.9
CBC
HGB - 131
RBC - 4.24
HCT - 0.37
PLT - 438
WBC - 17.6
228A SALANDAN Mannitol 100cc/IV Push 6/24 For transfer to PGH

Q12 Blood Chem
For Transfer to PGH Quetiapine 25 mg/tab 1 tab Na 132
PRN for agitation and or K 4.08
difficulty sleeping Mg 2.16
Diazepam 5 mg/IV iCa 1.29
Ivabradine 7.5 mg/tab 1 tab Crea 0.61
BID eGFR 132
Acyclovir 600 mg/IV Q8
Ceftriaxone 2g/IV in 90 cc CBC
PNSS for 1-2 hours Q12 Hgb 141
Prednisone 10 mg/tab 1 tab RBC 4.86
for 2 weeks Hct 0.41
Valproic Acid 250 mg/5mL Plt 449
15 mL TID WBC 34.61
Apply Calmoseptine to N 0.89
inner thigh on right medial L 0.06
TOTAL PATIENTS: 39
thigh M 0.02
Clonazepam 2g/tab 1 tab E 0.03
BID
Levetiracetam 15 mL Q12 6/21
Omeprazole 40 mg/IV PCR Japanese B Encephalitis Negative
Lacosamide 200 mg.IV BID
Levetiracetam 100 mg/tab 1
tab Q6
Ivabradine 7.5 mg tab 1 tab
BID
Clindamycin 300 mg/tab1
tab Q6
Paracetamol 600 mg/IV
PRN as needed for fever
temp >37.8 Q6 RTC
MEDICAL ICU (0M, 2R)
MICU-B Atorvastatin 40mg + 06/18 Awaiting:

LOPEZ, Neil Ezetimibe 40mg/tab Na 147 K 4.10 - 24H Holter Monitoring
54/M Lactulose 30 ml OD - 2D Echo w DS, Carotid Studies
Diazepam 5mg/IV PRN 06/17 - CXR
Main Service: Neuro Omeprazole 40mg/tab OD Na 147 K 3.69 Crea 2.13 eGFR 86
Referrals: Paracetamol 1g/IV Q6 PRN
Endo for pain 06/16 Pending:
Nephro Paracetamol 500mg/tab Q4 Na 151 K 3.69 Mg 3.19 - Blood CS, ETA GSCS, WAB UTZ, Deep Skin
CV PRN if ≥37.8C Tissue GSCS
Pulmo Ceftazidime-Avibactam 06/15 - CT Scan, R Flank w Contrast, FIT
ID 1.25gm/IV in 50mL St. H2O Na 153K 3.31 - Crea, Mg (next blood draw)
ENT Q8 - Na, K, Mg, CBC
Surgery Diltiazem 90mg/tab BID 06/14
- Urethral discharge GS,CS
Anes NAC 600mg/tab in ½ glass Na 150 K 3.40
Rehab H2O BID - CXR and ABG (6/14/24)
Derma Enoxaparin 0.4mL/SC OD 06/12 - Femoral catheter for bacterial GS/CS if
Uros Moxifloxacin 400mg/tab Na 145 K 5.28 amenable, but blood CS (2 sites) must still be
Int Cardio Q24 prioritized (06/18/24)
Albumin 20% d 4hrs. OD 06/11 - Wound bacterial GS/CS (ID) (06/18)
Assessment: Malignant Bilastine 20mg/tab BID Na 145 K 5.28 Crea 2.13 eGFR 36
Ischemic Stroke Ambroxol 75mg/tab 1 tab
OD 06/10
Nebivolol 10mg/tab tab OD Na 142 K 5.08 Crea 2.05 eGFR 38 - Bronchoscopy (06/10 12NN) and Central Line
KCl syrup QID Hgb 68 Hct 0.21 PC 224 WBC 18.10 Insertion done
Fenal cap, 1 cap OD
06/08 06/16/2024
Terazosin 20mg/tab 3 tabs Na 144 K 5.63 For Crea, Na, K, tomorrow at 6am
OD
Blood Cs 2 sites
Amlodipine 10mg/tab 06/07
Clonidine 150mcg/tab Q6 Na 144 K 6.05 Mg 3.19 Crea 1.93 eGFR 1.93 Wound CS, deep tissue from the left leg and right
Telmisartan 80mg/tab OD forearm
06/03 Penile purulent discharge , bacterial GS/CS
Na 144 K 6.05 Fecalysis, c.diff assay
Ipratropium neb q8L
NSS with NAC ICC Neb 06/16/24
q6h Na 151 K 3.69 Mg 2.24
Budesonide neb Q12 CBC hgb 92 hct 0.28 rbc 3.10 plt 253 wbc 21.20 n 0.98 l 0.01 m
0.01
HR Correction Scale
starting at 181mg/dL Urinalysis (06/14/24)
NPH 16u/sc Q12 Light yellow, turbid
HR 16u/sc prefeeding Q4 pH 5.0 Sp. gr. 1.020 albumin 2+ sugar - leukocytes + erythrocytes +
bilirubin - nitrite - ketone - urobilinogen normal
06/16/2024 RBC *over 100; pus cell *over 100; yeast cell ++ squamous cell
Vancomycin 1.25g/IV ++++ renal cell - transitional epithelial cell few bacteria ++++ mucus
threads - amorphous urates + uric acid - calcium oxalate -
amorphous phosphate - triple phosphate -
Hyaline - granular - waxy - RBC cast - WBC cast -
TOTAL PATIENTS: 39
*No dysmorphic RBC seen; presence of hyphal elements
MICU-D Paracetamol 500mg/tab Q4 06/04 Awaiting;

SORDILLO, Lucia PRN Na 133 K 4.46
74/F Atorvastatin 40mg/tab Pending:
ODHS - Repeat Na, K
Main Service: Neuro Pantoprazole 40mg/tab OD - iPhos, Cl
Referrals: Lactulose 30mL ODHS - CPAP
CV Carvedilol 12.5g/tab BID
- UA (Urine analysis)
Pulmo NAC 600mg/tablet in 1
ENT glass H2O BID - Repeat serum K, iCa, Mg, BC, if amenable
Endo Bilastine 20mg/tab 1 tab - Crea, albumin
Derma BID
Fam Med
Dietary ORS sachet in 200mL H2O
to replace losses vol/vol
Assessment: Mupirocin ointment on
Acute Cerebral Infarct, R erosions on gluteal area
Frontotemporoparietal, R Miconazole ointment under
MCA Territory probably breast and axilla
Cardioembolic in Origin; Triamcinolone on affected
Candidal Intertrigo area BID
S/p tracheostomy 06/04 HR Scale starting at

181(hold for 8PM feeding)
Hold Insulin for CBG
≤90mg/dL
Insulin 70/30 20u/sc
prefeeding (8PM)
Give ½ vial of D50 for CBG
<100mg/dL
Insuget 70/30 22 u/sc twice
daily
COVID WARD (3M, 0R)
303 Telmisartan 80mg/tab 1 tab 06/19 06/14 Awaiting:

MONREAL, Alaina OD LDH 260H Na 131 K 3.69 Mg 1.56 HSCRP 22.53 VTL 15.20 WAB CT Scan
90/F Ferrous sulfate + Folic acid Acute appendicitis. Appendiceal tip is likely ruptured demonstrating Pending:
1 tab OD (to consume Hgb 101 Hct 0.30 RBC 3.41 PC 246 WBC 4.10 Neu 0.62 Lym 0.35 surrounding inhomogenous fluid densities and thickened transversus - RLQ UTZ on 06/19
Main: Pedia stock) Mon 0.01 Eos 0.02 abdominis muscle. Peripherally enhancing fluid in the anterior - LDH HSCRP IL-6 Lactate D-dimer Procalcitonin
Co-managed: ID Sucrosomial iron + FA abdominal wall-subcutaneous region may represent anterior -ua, crea
Referrals: Hema, GS sachet OD 06/18 abdominal wall abscess formation.
Meropenem 1g in 90cc Blood with ARD, Left Arm CS: No growth after 5 days incubation Hyperenhancing lesion in pacreativ tail. This may be neoplastic in
Assessment: PNSS x 1-2 hours q8 Blood with ARD, Right Hand CS: No growth after 5 days incubation etiology.
COVID-19 confirmed Remdesivir 100mg in 20cc Descending colon diverticuloses
CAP-MR; Case of sterile water then dilute in Na 135 (L) K 3.49 (L) Hepatic cyst, segment VII
ruptured AP, anterior 230cc PNSS to run for 102 06/16 Renal cortical cysts, left (Bosniak I)
abdominal wall abscess; hours q24h Wound discharge CS Small, fat containing umbilical hernia
Anemia, IDA t/c Enoxaparin 0.4 mL/Sc OD Culture: Staphylococcus aureus Atheromatous abdominal aorta and its iliac branches
Lymphoma, primary Amlodipine 5 mg/tab OD Sensitivity: Osteopenia
marrow disease, t/c NAC 600 mg/tab 1 tab in ½ Sensitive to: Erythromycin Vancomycin Clindamycin Tetracycline Hypertrophic degenerative changed of the visualized thoracolumbar
Hypovolemic glass H2O Linezolid spine
hyponatremia, moderate KCl Tab 1 tab QID Resistant to: Penicillin Oxacillin TMP-SMX
06/13
Wound discharge CS
Culture: Escherichia coli 12L ECG
Sensitivity: VRate 75/min PR 0.16 QRS 0.08 QTA 0.36 QRS +45 Sinus
Sensitive to: Cefuroxime, Cefepime, Meropenem, Tobramycin, arrhythmia, normal 12L ECG
Cefoxitin, Ertapenem, Amikacin, Ciprofloxacin, Ceftriaxone,
Imipenem, Gentamicin, Levofloxacin
Intermediate to: Coamoxiclav
Resistant to: Ampicillin, Piptazo, TMP-SMX, Cefazolin
Urine CS
TOTAL PATIENTS: 39
Culture: Escherichia coli

Sensitivity:
Sensitive to: Co-amoxiclav, Cefuroxime, Ceftriaxone, Cefepime,
Meropenem, Tobramycin, Piptazo, Cefoxitin, Ertapenem, Amikacin,
Ciprofloxacin, Cefazolin, Ceftriaxone, Imipenem, Gentamicin,
Levofloxacin
Resistant to: Ampicillin, TMP-SMX, Tetracycline
Sputum CS
Culture: Escherichia coli
Sensitivity:
Sensitive to: Cefuroxime, Cefepime, Meropenem, Tobramycin,
Piptazo, Cefoxitin, Ertapenem, Amikacin, Ciprofloxacin, Ceftriaxone,
Imipenem, Gentamicin, Levofloxacin
Resistant to:
Ampicillin, Cefazolin, TMP-SMX
06/14
Urine GS
No microorganisms seen on both uncentrifuged and centrifuged
samples
06/13
SAR COV 2 Antigen NEGATIVE
Sputum GS
Gram + cocci in pairs: Few
PMN Leukocytes: > 25/lpf
SEC: 0-5/lpf
Wound GS
No microorganisms seen; Pus cells: ++
Reticulocyte count: 29H
Ferritin 1145H Iron 24.32L TIBC 137.52L

AST 24.50 ALT 28.40 Total Protein 6.72 Alb 3.73 Glob 2.99 A/G ratio
1.25 Na 126L K 4.91 HbA1c 6.04% Crea 0.82 eGFR 68
Hgb 64L RBC 1.87L Hct 0.19L PC 245 WBC 7.90 Neu 0.80 Lym
0.18 Mon 0.01 Eos 0.01
308 Omeprazole 40mg/IV q12 06/21 06/19 Awaiting:

GOZAR, Maria Rita Prednisone 5mg/tab OD D-dimer 9.59 PLAIN FILM OF THE ABDOMEN Pending:
61/F Levetiracetam 500mg/tab Gas distended bowel segments are seen.
OD 06/20 Distal bowel gas is visualized.
Main: MedOnco Azithromycin 500mg/IV OD UA
Some mottled radiolucencies are seen scattered throughout the
Referral: Dexamethasone 6g/IV dark yellow, sl turbid, 6.0, 1.010, sugar 1+, albumin 2+, rbc 3-6, pus
GI Q24H colon representing fecal materials, which are more prominent in the
10-15, epithelial ++, bacteria +, urates +, hyaline cast 4, granular
ID Levofloxacin 750mg/IV ascending and rectosigmoid colons.
cast 3, no dysmorphic rbc seen
Q24H A soft tissue density is noted at the left upper hemiabdomen.
Assessment: Meropenem 1g/IV Q8H Psoas shadows and flank stripes are intact.
Renal Cell CA STIV; Piptazo 4.5g/IV Q6H Sputum aspirate
A radio opaque tubular structure is noted overlying the right upper
COVID-19 Severe Meropenem 1g/IV Q8H Gram stain Gram positive cocci in pairs: +
hemiabdomen.
PMN >25
Surgical staples are noted overlying the right upper quadrant of the
Squamous >25
abdomen.
SARS COVID RAT POSITIVE
PT 13.6 sec, PT ratio 1.1, INR 1.2 CXR

IMPRESSION
Hgb 85, Hct 0.28, Plt 449, WBC 3.77, N 0.85, L 0.14, M 0.01 PNEUMONIA, RIGHT PARACARDIAC REGION.
ELEVATED RIGHT HEMIDIAPHRAGM.
BUN 13.80, Alk phos 619 (H), AST 203.90 (H), ALT 81.50 (H), Total MAGNIFIED CARDIAC SIZE.
protein 5.48 (L), Albumin 2.88 (L), Globulin 2.60, A/G ratio 1.11, Total ATHEROMATOUS AORTA.
TOTAL PATIENTS: 39
bilirubin 3.64 (H), direct 3.51 (H), indirect 0.13 (L), Na 132 (L), K 2.96
(L), Cl 95.90 (L), Mg 1.67, iCa 1.22, Crea 0.69, eGFR 99
309 Piperacillin-Tazobactam 06/18 06/15 Awaiting:

POON, Jaime 4.5g/IV Q6H Blood with ARD, Left Arm CS, Strep. Gallolyticus PORTABLE CHEST -Blood CS X 2 Sites
86/M Levofloxacin 750mg/IV Sensitive to: Penicillin Ceftriaxone Ampicillin Vancomycin Cefotaxime Pulmonary vascular markings are accentuated. -Sputum GS then CS PMN >25
Q24H Intermediate to: None Interstitial infiltrates are seen in both lower lung fields. -UA
Main: Pulmo Spiolto 2 puffs OD Resistant to: None The heart is enlarged.
Referral: CV, ID Symbicort Inhaler BID Aorta is tortuous. Pending:
Diltiazem 30mg/tab BID Coagulation Assay Diaphragm and both costophrenic sulci are intact. - 2D Echo with DS
Assessment: Irbesartan 150mg/tab ½ tab PT 14.9 PTR 1.2 INR 1.3 aPTT 40.8 IMPRESSION - Ferritin. LDH, IL-6, Procalcitonin, HSCRP,
OD BEGINNING CONGESTIVE CHANGES. CONCOMITANT Lactate
Salbutamol + Ipratropium CBC HGB 107 (L) RBC 3.48 (L) HCT 0.31 (L) PLT 308) WBC 8.20 N PNEUMONIA CANNOT BE RULED-OUT. CARDIOMEGALY. - ABG, CBC, Crea, LDH, HsCRP, CXR
Neb Q4H 0.93 (H) L 0.06 M 0.01 ATHEROMATOUS AORTA.
Dexamethasone 6mg/IV
Q24H Procalcitonin 0.06 (L) IL-6 211,20 (H)
Enoxaparin 0.4 ml SQ OD
Remdesivir 100mg in 20cc AST 20.70 ALT 29.80 LDH 269 (H) Na 131 (L) L 4.40 hsCRP 48.75
sterile water (H) Crea 1.51 (H) eGFR 45
Levocetirizine +
Montelukast 10/5mg/tab 06/17
ODHS BLood with ARD, Left Arm CS: Positive for bacterial growth after12
Levopront 10mL TID hours incubation
Lactitol 30cc ODHS
Anti-HCV 0.05 NONREACTIVE
CBG monitoring 06/16
Salinase spray 1 spray TID Anti-HCV 0.05 NONREACTIVE
Systane ultra drops PRN Anti-HBc Total 0.15 NONREACTIVE
HBsAg 0.33 NONREACTIVE
HBeAg 0.45 NONREACTIVE
Anti-HBs 1.09 NONREACTIVE
pH 7.514 pCO2 29.9 HCO 24.3
Procalcitonin 0.14L IL-6 163.30H Ferritin 1043H
Na 130L K 4.43
pH 7.509 pCO2 30.5 HCO3 24.4
06/15
LDH 243 (H) Mg 2.00 iCa 1.23 CRP 428.09 (H) Lactate plasma 1.55
ALT 29.00 AST 28.9
SARS-CoV-2 Antigen POSITIVE
pH 7.457 pCO2 32.1 HCO3 22.9
SAN LORENZO WARD (0M, 7R)
230A Clopidogrel 75mg/tab OD Awaiting:

TAMAYO, German Vitamin B Complex
100mg/tab BID Pending:
Main Service: Psych Pitavastatin 4mg/tab OD
Referrals: PM
Endo Linagliptin 5mg/tab OD
GI Mesegor Vita Tablet ODHS
Quetiapine 50mg/tab ODHS
Assessment: Pregabalin 75mg/tab OD
Persistent Depressive Vorteoxitine 10mg/tab OD
Disorder with Major AM
Depressive Disorder Lactulose 45mL ODHS
TOTAL PATIENTS: 39
episode in current episode

with suicidality
231A 06/16 06/16 Awaiting:

RABUTIN, Chantelle M. AST 12.40 ALT 11.20 SFA -TSH, FT3, FT4
24/F Multiple mottled densities are seen in the colonic segments - COVID RT PCR
PT 12.2 INR 1.0 PTT 34.5 IMPRESSION:
Main service: Psych FECAL RETENTION Pending:
Referrals: Pulmo Urinalysis Yellow sl. Turbid pH 5.0 SG 1.020 Leu + Ketone + RBC - 12L ECG
0-1/hpf Pus 2-4/hpf SEC FEW Bacteria + Mucus + 06/15 - AST ALT CK Total CKMB CKMM on 06/17
Assessment: Chest Xray
Major Depressive Hgb 136 RBC 4.71 Hct 0.42 PC 244 WBC 5.50 Neu 0.66 Lym 0.32 There are hazed densities seen in the RLLF
Disorder, Toxic Ingestion Mon 0.02 Heart is not enlarged
Diaphragm and both costophrenic sulci are intact
BUN 9.10 AST 17.20 ALT 13.50 CK Total 203H CKMB 11.70 CKMM IMPRESSION:
191.3H Na 134 K 4.58 Cl 99.70 Mg 2.06 iCa 1.25 Crea 0.80 eGFR CONSIDER PNEUMONIA, RIGHT LOWER LUNG FIELD. KINDLY
105 CORRELATE CLINICAL FINDINGS.
232 Valproic Acid 500mg/tab 06/10 Awaiting:

LANDERO, Ruth BID Na 137, K 4.24
31/F Neurotain Plus Tablet OD Pending:
Quetiapine 100mg/tab BID
Main Service: Psych Clonazepam 2mg/tab PRN
Referrals: CV Aripriprazole 5mg/tab BID
Quetiapine 100mg/tab
Assessment: ODHS
234 Lactulose 3.35g/5mL 30cc Awaiting:

JUCO, Rufino Angelo III ODHS
36/M Bisoprolol 5mg/tab OD Pending:
Clozapine 100mg/tab BID
Main Service: Psych Risperidone 2mg/tab BID
Referrals: CV Ivabradine 7/5mg/tab BID
Paracetamol 500mg/tab Q4
Assessment: PRN
231F Sertraline 50mg/tab Awaiting

MENDOZA, Roxanne Brexpiprazole 1mg/tab
Marie Kathlyn Valsartan 80mg/tab Pending:
31/F Empagliflozin + Metformin 12L ECG
BID
Main service: Psych Rosuvastatin 10mg/tab
Referrals: CV, Endo ODHS
231D Awaiting
MANUEL, Hannah Elise
22/F Pending:
Main service: Neuro

Referrals: GI
231H Awaiting
GALENDEZ, Irish
32/F Pending:
- For 12L ECG 6/10 8pm (48 hours post initiation
Main service: Psych of quetiapine)
Referrals: CV
231A Mannitol 100cc/IV push 06/18 Awaiting

SALANDANAN, Rica Quetiapine 100 mg/tab ½ Procalcitonin 0.06
Irish tab Pending:
19/F Diazepam 5 mg/IV ECG
TOTAL PATIENTS: 39
Levetiracetam 100 mg/mL

Main service: Psych Carvedilol 25 mg/tab
Referrals: CV Amlodipine 10 mg/tab
Ivabradine 7.5 mg/tab
Omeprazole 40 mg/tab
Paracetamol 600 mg/IV
Acyclovir 600 mg/IV
Ceftriaxone 2g/IV
Valproic acid 250 mg/5mL
Prednisone 20 mg/tab
Telmisartan 80 mg/tab
230C
REYES, Allen Christian
24/M
Main Service: Psych

Referrals: Pulmo, CV
DISCHARGED (1M, 3R)
205B Trimetazidine 35mg/tab BID 06/17 06/11 Awaiting:

ILAGAN, Expectacion Enoxaparin 0.4IV/sc OD ABG UTZ of Both Hemathoreces - Procalcitonin
93/F Atorvastatin 40mg/tab 1 tab pH 7.46 pCO2 39.30 pO2 68.50 HCO3 28.20 FiO2 21% O2 Sat PLEURAL EFFUSION, RIGHT, WITH SEDIMENTS AND/OR
OD 9.20% BE 4.80 RR 17 pf ratio 326.19 dFiO2 23.37% aAO2 0.68 a-A Pending:
CELLULAR DEBRIS, AS WELL AS, ASSOCIATED PASSIVE
Main Service: CV Clopidogrel 75mg/tab 1 tab gradient 32.11 - sputum gs/cs
Referrals: OD Interpretation: ATELECTASIS OF THE ADJACENT LUNG SEGMENTS - gene expert
Pulmo Pantoprazole 40mg/cap 1 Uncompensated Metabolic Alkalosis with Normal Oxygenation On PLEURAL EFFUSION, LEFT, WITH ASSOCIATED PASSIVE - rpt CBC, Na, K, iCa, ABG
ID - signed out cap OD Room Air (by AGE) ATELECTASIS OF THE ADJACENT LUNG SEGMENTS.
EOLCP (withhold Digoxin 0.25mg/tab 1 tab 06/14 Refused:
resuscitation, defib, q48h 06/10 NGT insertion & serum troponin-I
breathing assistance, Paracetamol 300mg/IV q6h Blood with ARD, Right ARM CS: No growth after 5 days of incubation 12-L ECG Enoxaparin 0.4u/SC
dialysis) PRN pain
1. Atrial Fibrillation with rapid ventricular response
Mupirocin Cream BID 06/09
Levofloxacin 750mg/tab PT 12.3 NC 12.9 PTR 1.0 INR 1.0 2. Left ventricular hypertrophy by Peguero-Lo-Presti
Assessment: q48 FT3 2.36 FT4 1.02 TSH 1.37 Criterion and Cornell criteria with strain and/or
CAP-MR, pleural effusion Eperisone 50mg/tab TID CBC HGB 120 HCT 0.36 PLT 246 WBC 6.20 N 0.67 S 0.67 L 0.28 M ischemia
0.02 E 0.03 3. Old inferior wall infarct
secondary to CAP-MR
CBG monitoring BID BUN 11.20 AST 46.50 (High) ALT 59.80 (High) TP 6.45 Alb 3.45
and CHF (EF 31%) prefeeding Glob 3.00 A/G 1.15 Na 139 K 3.97 Crea 1.06 (High) eGFR 49 06/09
WOF: Bradycardia and PORTABLE CXR
Desaturation Reticular densities are seen in both upper lung fields
Apical pleural thickening is noted on the right
MGH There is accentuation of the pulmonary vascular markings
Trachea is deviated towards the left side
Heart is enlarged
Aorta is tortuous and calcified
Veil-like densities are seen in both lower lung fields obscuring the
hemidiaphragms and both costophrenic sulci
Impression:
CONSIDER PTB, BOTH UPPER LUNG FIELDS
APICAL PLEURAL THICKENING, RIGHT
CARDIOMEGALY WITH CONGESTIVE CHANGES
ATHEROMATOUS AORTA
PLEURAL EFFUSION, BILATERAL, CONCOMITANT PNEUMONIA
CANNOT BE RULED OUT
12L-ECG
Rhythm: Atrial Fibrillation
TOTAL PATIENTS: 39
Ventricular rate: 100/minute

QRS 0.08sec
QTA 0.32sec
QRS axis +30 degrees
- Atrial fibrillation with average ventricular response with
isolated ventricular ectopic beats
- Abnormal precordial R wave progression
- LVH by Peguero-Lo-Presti criterion
- Non-specific ST-T wave abnormality
219D SALVADOR 06/07 06/07

Main: PRAS FBS 5.33 12L ECG
Referral: CV, ENDO BUN 5.90 Sinus Bradycardia, IV conduction delay
Crea 135.00
BCC, L cheek
UA 460.94 06/07
For wide excision Tomo Cholesterol 5.08 CXR
HbA1c 5.40 No active parenchymal infiltrates seen Heart is enlarged. Aortic
knob is calcified. Diaphragm and sulci are intact. Osteophytes
S/P Excision of Basal cell are seen in the thoracic spine.
CA Left cheek 06/20 IMPRESSION: CARDIOMEGALY ATHEROMATOUS AORTA
THORACIC SPONDYLOSIS
MGH
Multiple transverse and longitudinal

KIDNEYS: Both kidneys are normal in size with slight
increased echo pattern The right kidney measures 11.6 x 5.1 x
4.1 cm with corticomedullary thickness of 1.3 cm The left
kidney measures 10.5 x 5.2 x 4.2 cm with corticomedullary
thickness of 1.4 cm No evidence of lithiasis or hydronephrosis
bilaterally cysts are seen measuring as follows: rght,upper- 1
x1.2 x T cm interpolar- 1.3 x 1.7 x 1.3 cm left upper- 2.7 + 3.1 X
2.8 cm lower- 3.8 x 3.8 x 3.7 cm, 1.2 x 1.9 cm interpolar- 1.1 x 1
cm IMPRESSION: BILATERAL DEGENERATIVE RENAL
CHANGES WITH CORTICAL CYSTS
URINARY BLADDER: Its wall is not thickened Pre void volume:
181 cc Post void volume: no significant residual
IMPRESSION: NO URINARY BLADDER PATHOLOGY
DETECTED SONOGRAPHICALLY
PROSTATE GLAND: It is enlarged with homogeneous
parenchyma grams)
Impression:
PROSTATOMEGALY

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Clinical Division Grand Census

DEPARTMENT OF INTERNAL MEDICINE

KALI DEL ROSARIO

MEDICAL COMPLEX (TOTAL: 11; 9M, 2R)

203A 07/02/24 07/01/24 Awaiting:

204A Tramadol 50mg/IV Q8 PRN 6/22/24 06/20 Awaiting:

INTERMEDIATE TO: NONE

206A Salbutamol + Ipratropium 1 06/22 06/19 Awaiting:

Negative for lithiasis. The pelvocalyceal complex is not dilated

The gallbladder measures 4.5 x 2.6 cm/(L x W). No abnormal

The spleen is not enlarged measuring 6.9 cm along its longitudinal

Negative for intrasplenic mass.

207A Colchicine 500mg/tab OD 06/19 06/16 Awaiting:

207B Piperacillin Tazobactam 4.5 06/19 06/17 Awaiting:

207C KALI Ceftriaxone 2g/IV in 90cc 06/23 Awaiting:

207C ZARASPE Piptazo 4.5g/IV 6/19/24 06/19 Awaiting:

207D MATEO Febuxostat 40mg/tab 06/19 Awaiting:

208A Paracetamol 300mg/IV Q4 06/18 06/14 Awaiting:

210A Meropenem 1g/IV in 90cc 06/23 06/20 Awaiting:

Na 138 K 3.59 Crea 2.66 (3.38) eGFR 23 (17)

UA: :Dark Yellow Turbid pH 5.0 SpGr 1.015 Albumin 4+ Sugar -

210B Meropenem 1g/IV Q8 6/22/24 06/18 Awaiting:

Blood with ARD, Left Arm C/S: No growth after 5 days

210C Paracetamol 500mg/tab, 1 06/21 06/06 Awaiting:

Wound tissue, Right foot

Wound tissue, Right foot

(+) E. faecalis moderate growth

210E Omeprazole 40mg/IV Q12H 06/20 06/20 Awaiting:

PT 15.5 INR 1.3 PTR 1.3

BUN 19 Na 124L K 4.1 Crea 0.87 eGFR 81 HBA1C 7.36H

211 A Amlodipine 5mg/tab 1 tab 05/23 Awaiting:

211B 06/24/2024 06/23/24 Awaiting:

Crossmatching: ABO A positive, Compatible in 3 phases

211B Omeprazole 07/01/24 07/02/24 Awaiting:

211C 06/20 Awaiting:

211D Folic acid tab 1 tab BID 6/22/2024 06/15 Awaiting:

211E Losartan 50mg/tab OD 7/1

212A Piperacillin Tazobactam 06/20 06/14 Awaiting:

Oral care with Procalcitonin 0.09L

212A LUSUNG, Nelia Piperacillin Tazobactam 06/22

SURGICAL COMPLEX (0M; 19R)

217D Mannitol 150 cc/IV q4 06/22/24 Pending:

ABO Typing “O” Positive

217E Azithromycin 250mg/5ml 06/19 KUB UTZ (06/16/24) Awaiting:

Potassium 3.17(L) ionized Calcium: 1.23 HBA1c: 11.57% Creatinine

219A Cefoxitin 2g/IV 06/16/24 05/03/24 Awaiting:

Na 140 K 3.7 Crea 0.93 eGFR 95

Mg 2.33 iCa 1.26 HbA1c 8.16

High Trop I 0.0136

UA Yellow clear SG 1.020 pH 6 RBC 1-3 WBC 1-2 Bacteria few

219C GUTIERREZ Forgram 2g/IV (On call to 06/16 Pending:

219E IRESARE Pending: Repeat UA on D5 Antibiotics (6/23)

220B DEQUILLA Enoxaparin 0.4mL/SC OD 06/22/24 05/01/2024 Awaiting:

ABO Typing “A” Positive

Urinalysis Light yellow Slightly turbid pH 7.0 SG 1.010 Alb 1+ Sugar

220F Esoget 40mg/IV 06/19 Pending:

221A Balallo 06/18 Pending: CT guided Biopsy

221C 06/05 Awaiting:

PSA: 1.62 ng/mL