Professional Documents
Culture Documents
IM CD CENSUS July 3, 2024 (for Printing)
IM CD CENSUS July 3, 2024 (for Printing)
IM CD CENSUS July 3, 2024 (for Printing)
NEW MAIN PATIENTS (1) NEW REFERRAL PATIENTS (2) MED COMPLEX (14) SURG COMPLEX (23)
PEÑAMANTE
SANTOS, ELMER (M: MedcOnco; R: GS, SARIO
204A SLW GALENDEZ
227A (M: Neuro; R: Pulmo, Anes, FM, Pain Med, 217C (M: Neuro R: CV,
231H (M: Psych R: CV)
CV, Endo) Nephro, Neuro, Derma, NeuroSx, Rehab)
Rad onco, Rehab)
CAYAPA
217D LIBAO SLW LANDERO
206A (M: Pulmo R: Endo, CV,
(SICU-B) (M: NeuroSx R: CV) 232 (M: Psych R: CV)
Ophtha)
MARIANO
DE GUZMAN SLW JUCO
207A 219B (M: NeuroSx R: IDS,
(M: Hema) 234 (M: Psych R CV:)
GS)
YUMUYA
(M: Pulmo R: Derma, CRUZ, ENRIQUE SLW SANTOS, B.
207B 219E
Neuro, ENT, ID, (M: ENT; R: CV, Anes) 233 (M: Psych R: CV)
Ophtha, Uro)
KALI CALPITO
SLW RIVERA
207C (IM; CV R: GI, Nephro, 221D (M: Nsx R: Neuro,
230E (M: Neuropsych R: CV)
Pulmo, Neuro) Nephro, CV)
RAGUDO
QUIZON SLW BARLAO
207D (M: Rheuma R: IDS, 221G
(M: Uro R: Anes, CV) 231I (M: Neuropsych R: CV)
Ortho Derma, CV)
CHAVEZ UY SALUDAGA
208A (M: Hema R: Pulmo, GI, 225A (M: Neuro R: CV, SICU-A (M: Neuro R: CV,
Ophtha, CV, Neuro, FM) Pulmo, NeuroSx, ID) Pulmo, Nephro)
LIM
(M: Hema R: GI, Pulmo, SANTOS, Von
208B 226A
ID, Nsx, Neuro, TCVS, (M: NSx R: ID, Rehab)
GS)
SORDILLO
LAGMAN
(M: Neuro; R: CV,
(M: Pulmo R: TCVS,
226B Pulmo, ENT, Endo,
209A Anes, Med Onco, CV,
Derma, Fam Med,
IDS, FM)
Dietary)
LEE
SAGUIBO
(M: Neurosurg R:CV,
210D (M: Hema R: Pain med, 227B
Nephro, Hema, ID,
Nephro, Rheuma)
Neuro)
DEL ROSARIO
LERMA
308 225B (M: Gyne R: Pulmo,
(M: Nephro R: ID)
Nephro, CV, GS, ID, GI)
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
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
Sepsis prob sec to pre-feeding 0.01 pattern and increased parenchymal echogenicity. Focal hypoechoic
nosocomia pneumonia vs area is noted in the periportal region. The intrahepatic ducts are not
dilated. The common bile duct measures 0.3
intrabdominal infection
06/10 The gallbladder measures 3.8 x 1.4 cm (L x W). No abnormal
Urine CS intraluminal echoes nor shadowing seen. The gallbladder wall is not
Dermatology’s Negative for bacterial growth thickened measuring 0.3 cm.
Assessment: Incidental findings: *yeasts isolate The pancreas measures 2.2 cm, 1.2 cm, and 0.9 cm, for the head,
Trauma-induced erosion body, and tail, respectively. Echo Pattern is uniform. No evident solid
secondary to removal of 06/08 nor cystic mass lesion seen in or at the region of the pancreas. The
durapore tape 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
Klebsiella pneumoniae axis. Negative for intrasplenic mass.
S/P transfusion of 1u The right kidney measures 10.7 x 3.7 cm (L x W) with a parenchymal
PRBC SENSITIVE TO: thickness of 1.5 cm and cortical thickness of 0.8 cm. It exhibits
CO-AMOXYCLAV normal parenchymal echogenicity. Anechoic foci are seen with the
WOF: Hypotension and CEFUROXIME one in the superior pole measuring 0.5 × 0.4 × 0.5 cm (L x AP x W),
Desats, Bradypnea 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).
GENTAMICIN Negative for lithiasis. The pelvicalyceal complex is not dilated.
S/P POCUS bilateral
PIPERACILLIN-TAZOBACTAM The left kidney measures 10.9 x 5.0 cm (L x W) with a parenchymal
hemothorax 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
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
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)
HRZE 3 tabs OD Squamous epithelial cells: 5-10/LPF PLEURAL EFFUSION WITH ASSOCIATED PASSIVE
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.
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 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.
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.
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
Hgb 107, Hct 0.32, Plt 250, WBC 11.20, N 0.71, L 0.24, M 0.03, E
0.02, B -
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.
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
(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.
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
209A
LAGMAN
Main: Pulmo
Referral: TCVS, Anes,
Med Onco, CV, IDS
Assessment:
Complicated Pleural
Effusion, Right t/c Lung
Adenocarcinoma;
Clinically Diagnosed PTB
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
06/18
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
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
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
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
06/12
Anti-nuclear antibody: Positive up to 1:40; Speckled
VTL 7.30ug/mL
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
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
210D
SAGUIBO
Main: Hema
Referral: Pain Med,
Nephro, Rehab Med
Assessment:
Hypercalcemia r/o
Malignancy; AKI st. 1
probably sec to
hypercalcemia probably
medication induced,
cannot rule out secondary
to multiple myeloma or
dehydration
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
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
Assessment: Sigmoid
Racecadot PTT 22.60 Normal Isthmus
Thymo Cystic nodule left lobe
Adenocarcinoma
ril
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
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
Yellow, sl turbid, 6.0, 1.005, albumin 3+, sugar neg, leu pos, ery pos, UNREMARKABLE STUDIES OF THE VISUALIZED PANCREAS,
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
Main Service:
Referral: Endo
Assessment:
Hypertension stage 2,
Controlled DMT2, AKI w/
CKD, Hypoalbuminemia,
GERD,
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 -
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
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
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
06/08
ABO Typing “AB” Positive
Ab Screening NEGATIVE
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
CYSTOPLASTY eGFR 33
(MACEDO) TECHNIQUE
Assessment:
Benign Prostatic
Enlargement
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
ESR >150H
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
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
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.
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
Assessment: Pancreatic
Head Mass; Well
Differentiated Pancreatic
NET s/p EUS Biopsy
(4/3/24)
Assessment:
Multinodular Toxic Goiter
Clinically and
Biochemically Euthyroid
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
Hgb 96 RBC 3.24 Hct 0.28 MCV 87.60 MCH 29.40 MCHC 33.60
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
Hgb 101 RBC 3.46 Hct 0.31 MCV 89.00 MCH 29.20 MCHC 32.80
RDW 13.10 MPV 8.80 PLT 256 WBC 14.80 Neut (segs) 0.80
Lymphocytes 0.17 Monocytes 0.02 Eosinophils 0.01
Assessment:
Cervical Cancer Stage
IIIB; Anemia, ongoing
correction; AKI stage I,
resolving on top of CKD;
Pneumonia in an
immunocompromised host
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
06/06
6:41 AM
Na - 150 mEq/L HIGH
K - 3.62 mEq/L
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
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
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
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
Urine CS
Culture: Escherichia coli
Sensitivity:
Sensitive to: Co-amoxiclav, Cefuroxime, Ceftriaxone, Cefepime,
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)
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: ++
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
Na 130L K 4.43
06/15
LDH 243 (H) Mg 2.00 iCa 1.23 CRP 428.09 (H) Lactate plasma 1.55
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.
231D Awaiting
MANUEL, Hannah Elise
22/F Pending:
231H Awaiting
GALENDEZ, Irish
32/F Pending:
- For 12L ECG 6/10 8pm (48 hours post initiation
Main service: Psych of quetiapine)
Referrals: CV
230C
REYES, Allen Christian
24/M
12L-ECG
Rhythm: Atrial Fibrillation
Ventricular rate: 100/minute
QRS 0.08sec
QTA 0.32sec
QRS axis +30 degrees
- Atrial fibrillation with average ventricular response with
Clinical Division Grand Census
DEPARTMENT OF INTERNAL MEDICINE
University of Santo Tomas Hospital
TOTAL PATIENTS: 36
July 4, 2024 (THURSDAY)