ADMISSION CONFERENCE

January 10-11, 2016

Drs. Fajardo/Lugue-Ng/De Guzman

JI Lacson/ P. Magtoto
 Census
Old New Total
3rd MB 8 1 9
3rd MT 5 0 5
5th MB 9 2 11
5th MT 9 0 9
8th MT 12 1 13
9th MT 4 0 4
ICU 5 1 6
CCU
Total 052 27 259
NAME AGE/S CC DIAGNOSIS ROOM
EX

EA 42/M Abdominal Acid peptic disease 510

Pain r/o acute pancreatitis
r/o acute coronary syndrome

ET 49/M Chest Pain Acute coronary syndrome vs. CCU

Unstable angina

GG 63/M DOB t/c Healthcare associated ICU

pneumonia vs. pulmonary
congestion from CKD; CKD stage
5 secondary to DM nephropathy
on RRT (TF) r/o ACS
SA 76/M Abdominal APD r/o surgical abdoment r/o CCU
pain AAA; Dilated cardiomyopathy;
PVCs in trigeminy

CF 39/F Epigastric Acid related dyspepsia, steroid- 525

pain induced; AGE; Hypertension stage
II controlled
NAME AGE/SEX Chief DIAGNOSIS ROOM
Complaint
GA 57/M Melena UGIB probably 818
secondary to BPUD;
Type II DM;
Hypertension; S/p
CVA with residual
right-sided weakness
PC 71/F Body t/c UTI; CAP; Type II 301
weakness DM poorly controlled;
CKD stage III
probably secondary to
DM nephropathy;
Hypertensive
cardiovascular disease
t/c Aortic stenosis
EA, 42/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o acute pancreatitis, r/o acute
coronary syndrome
Room No: 510

CBC
Examination Result Ref range
Hgb 155 140-175
Hct 0.45 0.41-0.50
RBC count 5.27 4.52-5.90
-MCV 85.8 80.00-96.10
-MCH 29.4 27.50-33.20
-MCHC 34.3 33.40-35.50
WBC count 13.37 4.5-11
-Neutro 0.78 0.18-0.70
-Lympho 0.14 0.10-0.48
-Mono 0.06 0.00-0.04
-Eosino 0.02 0.00-0.03
Platelet count 286 150-400
EA, 42/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o acute pancreatitis, r/o acute
coronary syndrome
Room No:

HGT: 153 mg/dL

Clinical Chemistry

Examination Result Ref range

Creatinine 104.03 71-115
Sodium 146 135-150
Potassium 3.67 3.50-5.50
EA, 42/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o acute pancreatitis, r/o acute
coronary syndrome
Room No:

Examination Result Reference Range Urinalysis Result

SGOT 25.37 0.00-35.00
SGPT 51.73 0.00-0.45
ALP 92.36 53.00-128.00
Amylase

Trop I
EA, 42/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o acute pancreatitis, r/o acute
coronary syndrome
Room No:
ECG
EA, 42/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o acute pancreatitis, r/o acute
coronary syndrome
Room No:

Whole Abdominal X-Ray (Upright/Supine)

EA, 42/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o acute pancreatitis, r/o acute
coronary syndrome
Room No:

Chest PA
EA, 42/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o acute pancreatitis, r/o acute
coronary syndrome
Room No:

Whole Abdominal Ultrasound

-awaiting
ET, 49/M
Chief Complaint: chest pain
Diagnosis: t/c acute coronary syndrome
Room No: CCU
CBC
Examination Result Ref range
Hgb 170 140-175
Hct 0.50 0.41-0.50
RBC count 5.57 4.52-5.90
-MCV 89.4 80.00-96.10
-MCH 30.5 27.50-33.20
-MCHC 34.1 33.40-35.50
WBC count 10.85 4.5-11
-Neutro 0.76 0.18-0.70
-Lympho 0.14 0.10-0.48
-Mono 0.08 0.00-0.04
-Eosino 0.02 0.00-0.03
Platelet count 256 150-400
ET, 49/M
Chief Complaint: chest pain
Diagnosis: t/c acute coronary syndrome
Room No: CCU

Examination Result Ref range

iCa 0.97 1.13-1.32
Examin Result Ref
Mg 0.70 0.73-1.06 ation range
Na 142.7 135-150 iCa 0.97 1.13-1.32
K 3.78 3.50-5.50 Mg 0.70 0.73-1.06
Creatinine 79.27 71-115 Na 142.7 135-150
SGPT 53.70 71-115 K 3.78 3.50-5.50
SGOT 44.99 0-35 Creatini 79.27 71-115
Troponin I <0.50 0-1 ne
CKMB 0.8 0-7.20
ET, 49/M
Chief Complaint: chest pain
Diagnosis: t/c acute coronary syndrome
Room No: CCU

Hgt: 113 mg/dL

Urinalysis Result
AWAITING
ET, 49/M
Chief Complaint: chest pain
Diagnosis: t/c acute coronary syndrome
Room No: CCU

Initial ECG
ET, 49/M
Chief Complaint: chest pain
Diagnosis: t/c acute coronary syndrome
Room No: CCU

Repeat ECG
ET, 49/M
Chief Complaint: chest pain
Diagnosis: t/c acute coronary syndrome
Room No: CCU

Repeat Trop I, CKMB

Examination Initial/Repeat Ref range

Trop I AWAITING 1.13-1.32
CKMB AWAITING 0.73-1.06
ET, 49/M
Chief Complaint: chest pain
Diagnosis: t/c acute coronary syndrome
Room No: CCU

CXR
GG, 63/M
Chief Complaint: body malaise
Diagnosis: Pulmonary congestion secondary to CKDr./o ACS
Room No: ICU

CBC
Examination Result Ref range
Hgb 85 140-175
Hct 0.26 0.41-0.50
RBC count 2.74 4.52-5.90
-MCV 93.8 80.00-96.10
-MCH 31 27.50-33.20
-MCHC 33.1 33.40-35.50
WBC count 4.82 4.5-11
-Neutro 0.88 0.18-0.70
-Lympho 0.07 0.10-0.48
-Mono 0.04 0.00-0.04
-Eosino 0.01 0.00-0.03
Platelet count 236 150-400
GG, 63/M
Chief Complaint: body malaise
Diagnosis: Pulmonary congestion secondary to CKDr./o ACS
Room No: ICU

Examination Result Ref range

iCa 0.97 1.13-1.32
Examin Result Ref
Mg 0.70 0.73-1.06 ation range
Na 142.7 135-150 iCa 0.97 1.13-1.32
K 3.78 3.50-5.50 Mg 0.70 0.73-1.06
Creatinine 79.27 71-115 Na 142.7 135-150
SGPT 53.70 71-115 K 3.78 3.50-5.50
SGOT 44.99 0-35 Creatini 79.27 71-115
Troponin I <0.50 0-1 ne
CKMB 0.8 0-7.20
GG, 63/M
Chief Complaint: body malaise
Diagnosis: Pulmonary congestion secondary to CKDr./o ACS
Room No: ICU

Hgt: 158 mg/dL

Urinalysis Result
GG, 63/M
Chief Complaint: body malaise
Diagnosis: Pulmonary congestion secondary to CKDr./o ACS
Room No: ICU

Initial ECG
GG, 63/M
Chief Complaint: body malaise
Diagnosis: Pulmonary congestion secondary to CKDr./o ACS
Room No: ICU

Examination Initial/Repeat Ref range

Trop I 3.29 1.13-1.32
CKMB 2.4 0.73-1.06
GG, 63/M
Chief Complaint: body malaise
Diagnosis: Pulmonary congestion secondary to CKDr./o ACS
Room No: ICU

CXR
SA, 76/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o sugical abdomen r/o AAA; dilated
cardiomyopathy, PVCs in trigeminy
Room No: CCU

Examination Result Ref range

iCa 1.08 1.13-1.32
Examin Result Ref
Mg 0.74 0.73-1.06 ation range
Na 141.8 135-150 aPTT 33.6 31.88-
K 3.78 3.50-5.50 43.68

Creatinine 146.27 71-115 34.5 30.1-38.3

SGPT 66.47 71-115 PT 14.0 10-14

SGOT 156.30 0-35 12.2 10.6-13.6
Troponin I <0.50 0-1 INR 1.17
CKMB 0.8 0-7.20
Amylase 119.7 0-100
ALP 83.65 53-128
SA, 76/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o sugical abdomen r/o AAA; dilated
cardiomyopathy, PVCs in trigeminy
Room No: CCU
Urinalysis Result
Color Yellow
Appearance Slightly
pH 7.45 7.35-7.45 turbid
pCO2 37 35- pH 6.0
45mmHg
Specific grav 1.010
pO2 79 80-100
Pus cells 0-2/hpf
mmHg
Red cells 0-2/hpf
HCO3 25.2 22-26
mEq/L Epth cells few

BE 1.3 +/1 Mucus few

2mmEq/L threads

SO2 96% 95-100% bactera moderate

negative negative
SA, 76/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o sugical abdomen r/o AAA; dilated
cardiomyopathy, PVCs in trigeminy
Room No: CCU

Initial ECG
SA, 76/M
Chief Complaint: abdominal pain
Diagnosis: Acid peptic disease r/o sugical abdomen r/o AAA; dilated
cardiomyopathy, PVCs in trigeminy
Room No: CCU

CXR
Constantino, Florasol
Chief Complaint: dizziness
Diagnosis: Acid related dyspepsia steroid induced; Acute
gastroenteritis; HPN stage 2 controlled
Room No: 525

Examination Result Ref range

Hgb 143 140-175
Hct 0.44 0.41-0.50
RBC count 5.18 4.52-5.90
-MCV 84 80.00-96.10
-MCH 27.6 27.50-33.20
-MCHC 32.9 33.40-35.50
WBC count 18.20 4.5-11
-Neutro 0.87 0.18-0.70
-Lympho 0.05 0.10-0.48
-Mono 0.06 0.00-0.04
-Eosino 0.02 0.00-0.03
Platelet count 332 150-400
Constantino, Florasol
Chief Complaint: dizziness
Diagnosis: Acid related dyspepsia steroid induced; Acute
gastroenteritis; HPN stage 2 controlled
Room No: 525

Examination Result Ref range

Na 139.4 135-150
K 3.85 3.50-5.50
Creatinine 61.81 71-115
Hgt: 100 mg/dL
Urinalysis Result
GA, 57/M
Chief Complaint: melena
Diagnosis: UGIB probably secondary to BPUD; TYPE 2 DM;
Hypertension; S/p CVA with residual right sided weakness
Room No: 820

Examination Result Ref range

iCa 1.13-1.32

Mg 0.73-1.06

Na 139.4 135-150
K 4.62 3.50-5.50
Creatinine 83.82 71-115
SGPT 11.29 71-115
SGOT 12.58 0-35
ALP 61.32 53-128 U/L
CKMB 0.8 0-7.20
GA, 57/M
Chief Complaint: melena
Diagnosis: UGIB probably secondary to BPUD; TYPE 2 DM;
Hypertension; S/p CVA with residual right sided weakness
Room No: 820

Examination Result Ref range

Hgb 115 140-175
Hct 0.34 0.41-0.50
RBC count 3.98 4.52-5.90
-MCV 85.9 80.00-96.10
-MCH 28.9 27.50-33.20
-MCHC 33.6 33.40-35.50
WBC count 8.61 4.5-11
-Neutro 0.82 0.18-0.70
-Lympho 0.10 0.10-0.48
-Mono 0.06 0.00-0.04
-Eosino 0.02 0.00-0.03
Platelet count 230 150-400
GA, 57/M
Chief Complaint: melena
Diagnosis: UGIB probably secondary to BPUD; TYPE 2 DM;
Hypertension; S/p CVA with residual right sided weakness
Room No: 820

aPTT Result
31.88-43.68 32.7
30.1-38.3 34.5
GA, 57/M
Chief Complaint: melena
Diagnosis: UGIB probably secondary to BPUD; TYPE 2 DM;
Hypertension; S/p CVA with residual right sided weakness
Room No: 820

Repeat Trop I, CKMB

Examination Initial/Repeat Ref range

Trop I 1.13-1.32

CKMB 0.73-1.06
PC, 71/F
Chief Complaint: Body weakness
Diagnosis: t/c UTI; CAP; type II DM poorly controlled; CKD stage 3
probably secondary to DM nephropathy; Hypertensive cardiovascular
disease t/c Aortic stenosis
Room No:

CBC
Examination Result Ref range
Hgb 121 140-175
Hct 6.35 0.41-0.50
RBC count 4.04 4.52-5.90
-MCV 86.1 80.00-96.10
-MCH 30.0 27.50-33.20
-MCHC 34.8 33.40-35.50
WBC count 14.49 4.5-11
-Neutro 0.90 0.18-0.70
-Lympho 0.05 0.10-0.48
-Mono 0.05 0.00-0.04
-Eosino 0.00-0.03
Platelet count 213 150-400
PC, 71/F
Chief Complaint: Body weakness
Diagnosis: t/c UTI; CAP; type II DM poorly controlled; CKD stage 3
probably secondary to DM nephropathy; Hypertensive cardiovascular
disease t/c Aortic stenosis
Room No:

HGT: 252 mg/dL

Clinical Chemistry

Examination Result Ref range

Creatinine 136.98 71-115
Sodium 137.8 135-150
Potassium 3.48 3.50-5.50
PC, 71/F
Chief Complaint: Body weakness
Diagnosis: t/c UTI; CAP; type II DM poorly controlled; CKD stage 3
probably secondary to DM nephropathy; Hypertensive cardiovascular
disease t/c Aortic stenosis
Room No:
ECG