UNIVERSITY OF SANTO TOMAS HOSPITAL

España, Manila

Department of Medicine
Private Division

June 04, 2024

Charito Malong-Consolacion, MD
Medical Director
University of Santo Tomas Hospital

Greetings in the name of St. Thomas!

This is to request for a copy of a clinical abstract for patient ORTIZ, Jesus Ambrocio admitted in
University of Santo Tomas Hospital, Room 4020 Del Pilar Ward. The abstract shall be used in order to
request for financial assistance.

The following are the pertinent details surrounding the patient’s case:
A. Name: ORTIZ, Jesus Ambrocio
B. Age and Gender: 61 year old male
C. Address: Barangay Bambang, Calaca City, Batangas
D. Attending Consultant: Dr. Dacayan, Mary Ann
E. Date Admitted: June 01, 2024
G. Final Diagnosis: Secondary pneumothorax; COPD not in acure exacerbation;
PTB, treatment completed
H. Reason for Request Financial Assistance
I. Medications:
1. KCl tab 1 tab TID x 9 doses
2. Mosegor Vita 1 tab OD
3. Lactulose 30cc ODHS

Respectfully yours,

Dr. Dacayan, Mary Ann / Ilona Tiburcio / Zeanne Nolasco

Attending Physician/ Pulmonology Fellow/ Resident-In-Charge
University of Santo Tomas Hospital

Note: This document is issued upon the patient or patient’s relative request. This cannot be used for medico-legal purposes.