ENDORSEMENT CENSUS - JUNE 17, 2024 v1

OSPITAL NG MAKATI
Sampaguita corner Gumamela St., Brgy. Pembo, Makati City, Philippines

Tel. +632 882 6316 to 36
PhilHealth Accredited
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
JUNE 17, 2024
(MONDAY)
ADMISSIONS OB WARD LR / DR GYNE WARD PERIPHERALS REFERRALS

OB 1 LUNA, MARICEL GUADAMOR OB 2 SIMBULAN, ABIGAEL ORANO Gyne 1 ESCIETE, MARIAFE GARA SARI 3 BED 3 LIPARDO, MARY GRACE CASTA 704 PICONES, JOSEL PASCUAL
OB 11 FERNANDEZ, MANNIE LOU NAMOCO OB 3 BACOD, ABBEGUEL DE PABLO Gyne 2 HILARIO, AILEEN MENDOZA ICU 508 DELOS SANTOS, AMPARO ANDRADE
OB 15 NATE, MA.TERESITA SODE OB 4 CADAYONA, APRIL REGINE PATLONAG Gyne 3 CAMPANIL, ANGELITA BENOSA
GYNE 3 BARTOLOME, GRACEL AMATORIO OB 5 ESPELIMBERGO, BERNADETTE ACUÑA Gyne 5 LANOSGA, CRISTINA BUGARIN
OB 9 RUBLICO, GWYNETH N/A Gyne 6 TANDOY, RIE MEI QUIJANO ARI Bed 5 FRANCIA, LYNETTE BUENAVISTA
OB 11 AZARIAS, JESSAH GABATINO ICU 513 QUIJANO , ROSA GABINETE
OB 13 MAHINAY, KIMBERLLY FELIZARIO ARI 2 Bed 5 LISONDRA, FLAVIANA CUISON
OB 16 MAGAMAY, NOREEN MAE BALAUT
OB 17 DAYAPDAPAN, JENNELYN NILLAS
OB 23 CABUENAS, JENELYN ABEÑON
HR 5 DEMAIN, RIZZA MAE CAHIMAT
ADMISSION
PATIENT INFORMATION DIAGNOSIS SUBJECTIVE/OBJECTIVE THERAPEUTICS LABORATORIES PLAN/NOTES Remarks
OB 1 G3P3 (3003) Pregnancy BP 110/70 DAT CBC with PC EINC

LUNA, MARICEL GUADAMOR Uterine HR 78 IVF: D5LR 1L + 10 u Date Hgb Hct WBC S L M E Plt DMPA
32 Delivered term, cephalic, RR 20 oxytocin x 30 gtts/min 06/17
YC live baby boy T 36.8 8.5 L 0.26 L 17.8 87 6 7 317
stat
AS 9,9 BW 3.75 kg BL 54 cm
06/17 10.4 0.31 10.8 76 16 6 1 333
06/17/2024 MI 39 weeks AGA I: 850
3896157 Anemia moderate O: 600 O+/NR
Dr. Odevilas/Tungcul, secondary to Urinalysis
Ballesteros (TL), de Paz/Pesigan, 1)poor nutritional intake Date Sugar Protein WBC RBC Epithelial Bacteria
Posadas/Vito, Jasarino 2) acute blood loss Anemia moderate secondary Iron sucrose drip: 2 amp 06/17 Neg Trace 2.2 141.7 H 71.2 H 3.1 Anemia moderate
to iron sucrose + 100 cc PNSS Ferritin (06/17): 17.09 secondary to
Previous LTCS I for 1)poor nutritional intake x fast drip – given 75g OGTT (06/02 Life nurture) @ 37w0d 1)poor nutritional intake
1452H/1521H malpresentation (Oct 2022, 2) acute blood loss Ferrous sulfate 325mg/tab FBS 75.71 2) acute blood loss
EBL 400 cc Osmak) (-) pallor 1 tablet 2x/day 1sthr 136.34 Continue present medication
VBAC I (2024, Osmak) (-) dizziness 2ndhr 136.34
(-) generalized weakness
By Operative Vaginal (-) palpitations
Delivery (Vacuum Pink palpebral conjunctivae
Extraction); Cervicovaginal
wall inspection; Right 06/18
Mediolateral Episiotomy 2100H dizziness-> BP 110/70,
with repair under CLEA HR 83 -> stat CBC
(June 17, 2024)
OB wise
For observation if with
OB wise recurrence of dizziness
(-) no profuse vaginal bleeding Cefuroxime 500mg tab 1 Continue present
(-) severe hypogastric pain tab every 12 hours x 7 medications and monitoring
days
Mefenamic acid
500mg/tab 1 tablet every
8 hours as needed non
pain
OB 11 G1P1 (1001) Pregnancy BP 110/70 DM diet CBC with PC EINC

FERNANDEZ, MANNIE LOU Uterine HR 75 IVF: D5LR 1L + 10u Date Hgb Hct WBC S L M E Plt Implant
NAMOCO Delivered Term Cephalic RR 20 oxytocin x 30gtts/min
06/17 12.6 0.38 11.7 76 15 6 3 216
26 Live Baby Girl T 36.8
NYC AS 9,9 BW 3.77 kg BL 54 cm B+/NR
MI 40 weeks AGA Urinalysis Gestational Diabetes
06/17/2024 Gestational Diabetes Gestational Diabetes Mellitus, Date Sugar Protein WBC RBC Epithelial Bacteria Mellitus, diet controlled
3932709 Mellitus, Diet Controlled diet controlled No meds for now 06/17 Neg Trace 0.3 6.0 18.9 5.8 CBG TID ACHS
Dr. Palomares/Tungcul, (-) polyphagia For 75g OGTT 4-12 weeks
Ballesteros (TL), de Paz/Pesigan, by Normal Spontaneous (-) polydipsia 75 grams OGTT (04/19/24, Guada health) @ 30w6d post partum
Posadas/Vito, Jasarino Delivery; Right Mediolateral (-) polyuria Fasting: 99 H
Episiotomy and Repair See CBG table 1ST HOUR: 165
Under Local Anesthesia 2ND HOUR: 144
(6/17/2024) Hba1c (06/17): 5.60 OB Wise
For possible discharge 24
OB Wise Cefuroxime 500mg tab 1 CBG monitoring hours postpartum
No profuse vaginal bleeding tab every 12 hours x 7 Date 1550H 1800H 2000H
No severe hypogastric pain days 06/17 111 119 121
Mefenamic acid
500mg/tab 1 tablet every
8 hours as needed non
pain
Ferrous sulfate 325mg/tab
1 tablet 2x/day
OB 15 G5P4 (4004) Pregnancy BP 120/70 DM diet + high potassium CBC with PC

NATE, MA.TERESITA SODE Uterine 35 weeks AOG by HR 98 diet Date Hgb Hct WBC S L M E Plt
40 LMP cephalic not in labor RR 20 IVF: Heplock
06/17 11.6 0.33 10.8 76 17 6 1 263
YC Gestational diabetes T 36.6 (+) cardiac monitor
mellitus, diet controlled A+/NR
06/17/2024 Hypokalemia secondary to Current Wt 75.7KG Urinalysis
3932684 hypokalemic Periodic Ht 161.5CM Date Sugar Protein WBC RBC Epithelial Bacteria
Dr. Palomares/Tungcul, Paralysis Allegedly with Prepreg Wt: 06/17 Gestational Diabetes
Ballesteros (TL), de Paz/Pesigan, Hypothyroidism 91kg None for now 06/ 17 Neg 1+ 28.9 H 2.2 361.9 969.8 H Mellitus, diet controlled
Posadas/Vito, Jasarino Advanced maternal age Prepreg BMI: 34.88kg/m2 Chemistry 7 pt CBG monitoring
Obese Date Na K Cl Mg For 75g OGTT 4-12 weeks
06/16 136.98 2.48 L 104 0.76 post partum
Gestational Diabetes Mellitus, Ferritin (06/17): 32.82
diet controlled 75g OGTT (03/21/24) @ 22w2d
(-) polyphagia FBS: 95.44 mg/dl H
(-) polydipsia 1st: 113.02 mg/dl
(-) polyuria 2nd: 132.76 mg/dl
See CBG table Hba1c (06/17): 4.76 Hypokalemia secondary to
12L ECG (06/17): NSR, NSSTWC hypokalemic Periodic
Paralysis
Hypokalemia secondary to Imaging For K correction
hypokalemic Periodic Potassium chloride BPS UTZ (06/16/24, Osmak) SLIUP Cephalic 35w0d 138 bpm AHL gr 2 2577 g SDP 5.02 cm 8/8 Ongoing K correction (TE
Paralysis 750mg/tab 2 tablets every BPS UTZ (05/28, Makatilife) SLIUP Cephalic 32w 143 bpm AHL gr 2 SDP 3.40 cm 1921 g 8/8 06/18 12nn)
(-) generalized weakness 4 hours for 6 cycles CAS (3/23/24) – MAKATI LIFE SLIUP breech 23 4/7 weeks 139 bpm 629g right lateral HL, gr I SVP: 3.6cm no gross fetal structural abnormality at time of scan Repeat K post correction
(-) difficulty ambulation Pantoprazole 40 mg/tab 1 IM Nephro (06/17)
(-) vomiting tab 30 mins pre breakfast Thyoid function test (06/18, OsMak) Dx:
(-) diarrhea TSH 1.32 Suggesting TSH, FT4, FT4 to
rule out hyperthyroid
FT3 1.96 L
ABG, KUB UTZ to rule out
FT4 0.92 L
Motor RTA
RUE 5/5 LUE 5/5 Urine K – to rule out renal
RLE 5/5 LLE 5/5 losses
Tracing
Sensory Date Interpretation BFHT Variability Acceleration Deceleration Contraction
100% 100% 06/18 AM Reactive 135-140 Moderate (+) (-) No contraction
100% 100% 06/17 PM Reactive 135-140 Moderate (+) (-) No contraction
06/17 AM Reactive 135-140 Moderate (+) (-) No contraction
Hypothyroidism
Hypothyroidism Referred to IM Endo (Dr.
(-) lethargy No meds for now CBG monitoring Pagarigan)
(-) cold intolerance Date 1400H 1700H 2000H 2100H
(-) sudden weight gain 06/17 86 119 75 125
(-) severe hair loss OB Wise
PLAN: For electrolyte
correction and workup of
hypokalemia
PROD informed (Dr. Almario)
For NST BID
Strict FHT q4 and record
OB Wise For 7pt CBG monitoring
Good fetal movement Ferrous sulfate 325mg/tab Monitor VSq4h I&O qshift
no watery vaginal discharge 1 tablet once a day [/] TFTs
no bloody vaginal discharge Multivitamins 500mg/tab [ ] ABG to rule out RTA –
1 tablet once a day amenable, for canvassing
G5P4 (4004) Calcium carbonate [ ] KUB UTZ to rule out RTA –
LMP: OCT 17, 2023 (unsure) 500mg/tab 1 tablet 2x/day on 06/20 9 AM c/o Dr. Torres
AOG: [ ] Urine K to rule out renal
35 by LMP losses – amenable, for
35 4/7 by UTZ (12/19=9w4d) canvassing
FH: 29 cm
EFW 2635 g by Johnson’s rule;
2500-2700 g by palpation
FHT: 140s
IE: cervix closed
GYNE 3 Nulligravid BPR 130-150/70-90 DASH diet with SAPIVF: CBC with PC
BARTOLOME, GRACEL AUB – L, M BP 130/70 IVF: PNSS 1L x KVO while Date Hgb Hct WBC S L M E Plt
AMATORIO Anemia severe secondary HR 97 on BT 06/1 0.20
39 to acute blood loss RR 20 (+) O2 support via nasal 6.6 L 8.4 60 31 8 1 506 H
7 L
NYC Hypertension st II, unknown T 36.7 cannula at 2-3LPM
O+/NR
control (+) cardiac monitor
Urinalysis
06/17/2024 Overweight I: 480 (+) IFC
Date Sugar Protein WBC RBC Epithelial Bacteria Leukocyte
3932717 O: 350
06/17 Neg Neg 2.7 4.4 28.5 10.6 neg
Dr. Palomares/Tungcul, Previous total
Ballesteros (TL), de Paz/Pesigan, thyroidectomy (2017, Wt: 57kg Chemistry
Posadas/Vito, Jasarino Chong Hua Hospital Cebu) Ht: 155cm Date BUN Crea AST ALT Na K Cl Hba1c
BMI: 23.72kg/m2 06/17 2.93 55.86 20.18 14.59 139.74 3.90 108.74 4.90
(Overweight) Coagulation studies
Date PT %activity INR aPTT
Anemia severe secondary to Ongoing BT of 1u pRBC 06/17 11.7 103.3 1.04 28.7 L
acute blood loss Diphenhydramine 50mg Ferritin (6/17/24 OSMAK): 10.10 L Anemia severe secondary to acute blood loss
(+) pallor TIM 30 mins prior to BT – Reticulocyte count (06/17): 3.5 H Ongoing BT of 1u pRBC (TE: 0530H)
(+) dizziness given 12L ECG(06/17): Sinus tachycardia, t wave inversion on lead VI, nonspecific twave changes in lead III For BT of 3u PRBC properly typed and cross
(+) generalized weakness Paracetamol 300mg TIV Pregnancy test (06/17): Negative matched to run 4hrs with interval of 2 hours
pale palpebral conjunctivae 30mins prior to BT Imaging (1130H)
Calcium gluconate 10% Chest Xrayi c/o Dr. Torres no acute opacities, probable cardiomegaly For repeat CBC 6hours post BT of 2 units pRBC
10cc SIVP post BT of 3u TVS UTZ (June 17, 2024, MEGASON) .99 and 3.27 x 2.95 x 4.04, respectively.
PRBC Several cystic foci are seen in the cervix, largest meas 0.68cm
R ovary: 2.35 x 1.2 x 1.66cm vol 2.44
L ovary: 1.69 x 1.77 x 1.66cm vol 2.59cc
No adnexal masses seen
Posterior cul de sac intact
IMPRESSION:
Hypertension st II, unknown Losartan 50mg/tab 1 Uterine myomas (FIGO 5) Hypertension st II, unknown control
control tablet per orem once a Thick hyperechoic endometrium BP monitoring and control
(-) dizziness day (AM) Unremarkable ovaries
(-) headache Amlodipine 5mg/tab 1 Nabothian cysts
(-) blurring of vision tablet per orem once a
day (PM)
Previous total thyroidectomy Levothyroxine 150mcg/tab

(-) lethargy 1 tablet per orem once a
(-) excessive hair loss day prior to breakfast Previous total thyroidectomy
(-) cold intolerance For referral to IM ENDO service once with results
of TFTs
[ ] For TFTs morning peak extraction 06/18
Ferrous Sulfate
Gyne wise 325mg/tab, 1 tab twice a Gyne wise
(+) vaginal bleeding day – HOLD for now while For anemia correction; possible endometrial
(-) severe hypogastric pain on BT biopsy once anemia corrected
Paracetamol + Tramadol Pad counting qshift
LMP: June 4-present 325mg/37.5mg/tab, 1 tab
PMP: May 10-15 per orem every 8hrs as
PMP: April 19-24 needed for pain
PMP: March 18-22 Tranexamic Acid 1g SIVP
every 8 hours for 24
Abdomen soft flabby, non- hours, then as needed for
tender, no palpable masses, profuse vaginal bleeding
no muscle guarding
SE: cervix pale, posterior, no
lesions, scanty bleeding per os
IE: cervix closed, firm 3x3cm,
posterior, no cervical motion
tenderness, uterus slightly
enlarged to 10 weeks size, no
adnexal mass nor tenderness
RVE: no skin tags, no anal
fissures, (+) good sphincteric
tone, no mass, free
parametria, no blood per
examining finger
Pad count: 1 pad moderately

soaked
LR DR
OB Ward
OB 2 G4P4 (4004) Pregnancy Uterine BP 110/70 DM diet CBC NICU for poor
SIMBULAN, ABIGAEL ORANO Delivered Term Cephalic HR 93 Date Hgb Hct WBC S L M E Plt APGAR score
27 Live Baby Girl RR 20 06/15 9.3 0.27 13.9 72 22 5 1 298 -> EINC
YC AS 3,5,7 BW 2.93kg BL 48cm MI T 37.0 06/13 11.8 0.34 9.7 66 27 6 1 313
37 weeks, AGA O+/NR A 0-0-1
06/13/2024 Gestational Diabetes Mellitus, Urinalysis P 2-2-2
3810767 insulin requiring G 0-1-1
Date Sugar Protein WBC RBC Epithelial Bacteria
Dr. Calo/ Tungcul, Bacterial vaginosis, ongoing A 1-1-1
06/13 Neg Neg 0.2 0.3 10.2 5.0
Ballesteros(TL)/ Gavino/ De tresatment R 0-1-2
75-g OGTT (4/28/24, MakatiLife)@ 28 weeks
Guia, Gallano/ Alzaga, Tiongson Previous LTCS x 2 (I for Gestational Diabetes Regular Insulin sliding scale –
FBS 90.24
prolonged deceleration phase Mellitus, insulin requiring HOLD Gestational Diabetes Mellitus, IUD
1st hr 215.28 H
0530H/0844H (-) polyphagia 110-150 2 units insulin requiring
with failure in decent, Category 2nd hr 139.93 H
EBL 1100cc (-) polydipsia 151-200 4 units CBG TIDACHS – discontinued
II tracing, 2014 OSMAK; II for HbA1c (06/13): 5.18%
(-) polyuria 201-250 6 units For 75 g OGTT 4-12 weeks
repeat, 2019 OSMAK) Ferritin (06/13): 103.2
See table 251-300 8 units postpartum
Vaginal discharge GS (06/13): SMEAR SHOWS PREDOMINANCE OF GRAM NEGATIVE LACTOBACILLI WITH FEW LEUKOCYTES AND MODERATE EPITHELIAL CELLS.
> 300 10 units
By Emergency LTCS III for repeat Vaginal discharge KOH (06/13): Negative
Endo notes (06/16)
with adhesiolysis and IUD CBG monitoring
Noted for discharge planning, no
insertion under CLEA (6/15/24) Date 0100H 0500H 0900H 1300H 1700H 1800H 2100H objection endo wise if for
06/17 107 DISCONTINUED discharge
06/16 98 107 102 105 For 75g OGTT 6 weeks post
06/15 95 106 102 117 partum
G4P4 (4004) 06/14 193 129 168 101 101 - -
s/p E LTCS III Day 3
Bacterial Vaginosis Metronidazole 500mg 1 tab 06/13 83 108 Bacterial Vaginosis
Gestational Diabetes Mellitus,
(-) foul smelling discharge every 12 hours for 7 days (D3) For completion of antibiotics
controlled
(-) pruritus
Bacterial vaginosis, ongoing
OB wise
treatment
Still for discharge (philhealth)
Previous LTCS x 2 (I for
OB wise Cefuroxime 500mg/tab 1
prolonged deceleration phase
(-) severe hypogastric pain tablet every 12 hours to
(-) profuse vaginal bleeding complete for 7 days
with failure in decent, Category
(+) flatus Mefenamic acid 500mg/tab 1
II tracing, 2014 OSMAK; II for
(+) BM tablet every 8 hours as
repeat, 2019 OSMAK)
needed ord pain
Ferrous sulfate 325mg/tab 1
tablet 2x/day
Tranexamic acid 1g TIV every
8 hours x 24hours- given
OB 3 G2P2(2002) Pregnancy Uterine BP 100/70 DAT CBC with PC NICU for
BACOD, ABBEGUEL DE PABLO Delivered term cephalic HR 89 IVF: D5LR 1L + 10u oxytocin x Date Hgb Hct WBC S L M E Plt maternal
24 Live baby girl RR 20 30gtts/min illness
YC AS 9,9 BW 3.17 kg BL 53 cm MI T 36.3 06/17 11.1 0.33 22.1 H 93 H 3 4 315 (GDM, UTI)
39 weeks AGA 06/16 11.9 0.36 13.8 78 15 6 1 352 IUD
3932653 Gestational Diabetes Mellitus, B+/NR
DR. Ordono/ Tungcul/ newly diagnosed Urinalysis
Gavino(TL)/ Gauiran Gallano/ Urinary tract infection Date Sugar Protein WBC RBC Epithelial Bacteria Gestational Diabetes Mellitus,
Alzaga Tiongson Gestational Diabetes None for now 06/ 16 NEG NEG 1.8 5.3 57.3 H 1218.7 H newly diagnosed
By Normal spontaneous Mellitus, newly diagnosed 06/16 NEG NEG 1.8 4.6 48.3 8282.6 H CBG TID ACHS
delivery; right mediolateral (-) polyphagia For 75g OGTT 4-12 weeks post
FBS (05/02, Satellite Lab) @ 33 weeks – 98.58
episiotomy and repair under (-) polydipsia partum
HbA1c (06/16/24) 5.15%
local anesthesia (06/17/2024) (-) polyuria
Ferritin (06/16/24): 20.23
See CBG table Urinary Tract Infection
ESR (06/17): 35 H Completion of antibiotics
CRP (06/17): >10.00 H
Urinary Tract Infection Cefuroxime 500mg tab 1 tab
CBG monitoring
(-) dysuria every 12 hours x 7 days
(-) hematuria 0500 1100H 1300H 1700H 2100H OB Wise
Date 0800H
(-) fever H Continue present medications,
06/17 99 78 79 88 144 monitoring, and management
06/16 91 For possible discharge today
OB Wise Mefenamic acid 500mg/tab 1
No profuse vaginal bleeding tablet every 8 hours as
No severe hypogastric pain needed for pain
Ferrous sulfate 325mg/tab 1
tablet 2x/day
OB 4 G1P1(1001) Pregnancy Uterine BPR 130-140/80-90 LSLF diet CBC with PC EINC
CADAYONA, APRIL REGINE Delivered term cephalic BP 130/90 IVF: D5LR 1L + 10u oxytocin x Date Hgb Hct WBC S L M E Plt DMPA
PATLONAG Live baby girl HR 89 30gtts/min
06/16 15.5 0.44 7.8 67 23 7 3 284
24 AS 9,9 BW 2.84 kg BL 50 cm MI RR 20
YC 38 weeks AGA T 36.6 B+/NR
Gestational Hypertension Coagulation Test
311983 Date PT % Act INR APTT
06/16/24 By Normal spontaneous delivery Gestational hypertension Nifedipine 30mg/tab once a 06/16 11.9 101.6 1.06 30.8
Dr. Palomares/Tungcul/ ;Right mediolateral episiotomy (-) headache day Urinalysis Gestational hypertension
Gavino(TL)/Gallano and repair under SAB anesthesia (-) dizziness Date Sugar Protein WBC RBC Epithelial Bacteria For BP monitoring and control
Gauiran/Alzaga Tiongson (06/17/2024) (-) chest pain 06/17 Neg Trace 1.8 0.3 23.8 2.5
(-) DOB/ SOB 06/16 Neg Neg 0.8 29.6 61.6 H 149.3 H
(-) vomiting Chemistry
Date BUN Crea LDH AST ALT
06/16 1.42 L 43.94 L 234.52 17.96 12.30
Ferritin (06/16/24): 102.0
24 hour urine protein (6/6/24, Micromedic Laboratory): 133.8
OB Wise Cefuroxime 500mg/tab 1
No profuse vaginal bleeding tablet every 12 hours to
No severe hypogastric pain complete for 7 days OB Wise
Paracetamol + Tramadol 325 Continue present medications,
mg/37.5 mg/tab 1 tablet monitoring, and management
06/17 2030H every 8 hours as needed for Referred to IM-Neuro (Dr.
(+) numbness of upper pain Pagarigan), awaiting notes
extremities Ferrous Sulfate 325mg/tab 1 [ ] Na, K, Cl – for extraction
(-) weakness tablet twice a day to
complete for 90 days
Patient is Oriented to 3
spheres, follows commands
CNs
II, III: (+) 3mm EBRTL
III, IV, VI: (+) EOMs, primary
gaze midline
V: V1-V3 intact; (+) visual
threat
VII: facial asymmetry, right
side
VIII: (+) gross hearing
IX, X: Can swallow
XI: Good shoulder shrug
XII: tongue midline
Motor
RUE 5/5 LUE 5/5
RLE 5/5 LLE 5/5
Sensory
80% 80%
100% 100%
OB 5 G1P1(1001) Pregnancy Uterine BP 120/70 Soft Diet then DAT once with CBC with PC EINC
ESPELIMBERGO, BERNADETTE delivered HR 88 BM Date Hgb Hct WBC S L M E Plt DMPA
ACUÑA Term cephalic, live baby boy RR 20 D5LR 1L x 30gtts/min 0.26
25 AS 9,9 BW 3.4kg BL 52 cm MI 39 T 36.9 06/16 8.6 L 14.0 82 11 6 1 194
L
NYC weeks AGA
06/16 10.7 0.32 9.4 62 23 9 6 249
Anemia Moderate secondary to
acute blood loss Anemia Moderate secondary Iron Sucrose drip: Iron B+/NR Anemia Moderate secondary to
3932202 Urinalysis
to acute blood loss Sucrose 2amps + PNSS 100 cc acute blood loss
06/16/2024 Date Sugar Protein WBC RBC Epithelial Bacteria
By Emergency LTCS I for arrest (-) pallor x FD - given Continue monitoring and
Dr. Odevilas/Tungcul, Go/ Reyes 06/16 Neg 3+ 2.7 20.5 26.7 60.0
in cervical dilatation under CLEA (-) DOB/ SOB Ferrous sulfate 325mg/tab 1 management
(TL), Roque (p) /Posadas,
(06/16/24) Pink palpebral conjunctivae tablet 2x/day Ferritin 06/16 263 H
Tugado/Kadappurath
OB wise
0747H/ 0848H
G1P1(1001) OB wise For possible discharge today
EBL: 700cc
s/p LTCS I for arrest in cervical No profuse vaginal bleeding
dilatation Day 2 No severe hypogastric pain Cefuroxime 500mg/tab 1
Anemia Moderate secondary to (+) Flatus tablet every 12 hours to
acute blood loss (-) BM – bisacodyl given complete for 7 days
Mefenamic acid 500mg/tab 1
tablet every 8 hours as
needed for pain
OB 9 G2P2(2002) Pregnancy uterine BP 90/60 DAT CBC with PC EINC

RUBLICO, GWYNETH N/A Delivered term cephalic HR 89 IVF: PNSS 1L x KVO while on Date Hgb Hct WBC S L M E Plt DMPA
23 Live baby girl RR 20 BT 06/17
NYC AS 9,9 BW 3.61kg BL 52cm MI T 36.7 O2 via NC at 2 lpm s/p BT 0.25 Given
39 weeks AGA 8.4 L 12.8 76 16 7 1 272 Methergine
of 1u L
3890734 Blood transfusion of 1 unit pRBC I: 2770 pRBC and Carbetocin
06/16/24 for Anemia Moderate secondary O: 1100 Anemia Moderate secondary to
06/16
Dr. Odevilas/ Tungcul/ Gavino to early postpartum early postpartum hemorrhage
nd
repeat
(TL)/ Gauiran/ Gallano/ hemorrhage secondary to Anemia Moderate secondary Ongoing BT of 2 u pRBC secondary to transient uterine
CBC 6
Tiongson, Alzaga transient uterine atony, to early postpartum s/p BT of 1 u pRBC 0.23 atony, medically managed
hours 7.8 L 17.9 84 9 7 276
medically managed hemorrhage secondary to Diphenhydramine 50mg TIM L s/p BT of 1 u pRBC
post
transient uterine atony, given Ongoing BT of 2nd u pRBC (TE:
partu
EBL: 1000cc By Normal Spontaneous medically managed Ferrous sulfate 325mg/tab 1 0700H)
m
Delivery; Right Mediolateral (+) slight pallor tablet 2x/day For repeat CBC 6 hours post BT of
06/16 10.3 0.30 9.4 75 17 6 2 284
Episiotomy with Repair under (+) slightly pale palpebral 2u pRBC (1300H)
Local Anesthesia (06/16/2024) conjunctivae O+/NR
(-) DOB/SOB Urinalysis
G2P2(2002) Date Sugar Protein WBC RBC Epithelial Bacteria
s/p NSD Day 2 06/16 NEG NEG 0.7 1.3 9.3 1.9
Blood transfusion of 1 unit pRBC Ferritin (06/16/24): 62.55
for Anemia Moderate secondary
to early postpartum Intraoperative findings: OB Wise
hemorrhage secondary to Initially, noted soft and boggy uterus. For anemia correction
transient uterine atony, Uterine massage done. Continue present medications
medically managed Uterotonics given. (Methylergometrine Maleate 125mg TIM; Carbetocin 1 amp TIV) and management
OB wise Cefuroxime 500mg/tab 1 Noted uterus was then well-contracted.
No profuse vaginal bleeding tablet every 12 hours to
No severe hypogastric pain complete for 7 days
Mefenamic acid 500mg/tab 1
tablet every 8 hours as
needed ord pain
Metronidazole 500mg tab 1
tab every 12 hours x 7 days
OB 11 G3P2 (2012) BP 110/70 DAT CBC with PC -

AZARIAS, JESSAH GABATINO Complete abortion HR 72 Date Hgb Hct WBC S L M E Plt
41 Non-septic, non-induced RR 20
06/13 10.3 L 0.32 L 6.6 62 27 9 2 470
NYC Pelvic inflammatory disease T 37
06/11 10.5 L 0.34 L 15.4 88 8 4 - 481
Tubo-ovarian abscess, left
O+/NR
06/11/24 Bacterial Vaginosis, treatment I: 175
Urinalysis
3931806 completed O: 1650
Dr Canaveral/ Anemia mild secondary to acute Date Sugar Protein WBC RBC Epithelial Bacteria Leukocyte
Tungcul/Ballesteros De Paz blood loss HT: 161cm 06/11 Neg Neg 6.5 531.2 H 26.7 11.7 Neg
/Gavino(TL)/Gauiran r/o Acute Diverticulitis WT: 73.5kg 06/11 Neg +1 H 22.1 H 32.7 H 54.4 H 122.4 Neg Anemia mild secondary to acute
Pesigan/Jasarino Vito Obese I BMI: 28.4 (obese I) Chemistry blood loss
Date Crea ESR CRP Continue present medications
Anemia mild secondary to Ferrous sulfate 325mg/tab 1 >10.00
06/12 45.77 1
acute blood loss tab 2x a day H
(-) dizziness Ferritin (6/11/24 OSMAK): 107.60 Bacterial vaginosis, treatment
(-) generalized body weakness Vaginal discharge GS (05/31 OSMAK): SMEAR SHOWS MODERATE GRAM POSITIVE LACTOBACILLI, FEW GRAM NEGATIVE BACILLI AND OCCASIONAL GRAM completed
(-) dyspnea POSITIVE COCCI IN SINGLY WITH MODERATE LEUKOCYTES AND EPITHELIAL CELLS No active management
(-) pallor Vaginal discharge KOH 05/31 OSMAK): Negative
Pink palpebral conjunctiva Imaging Pelvic inflammatory disease
Uterus: 5.67x6.61x6.36cm For completion of antibiotics
Bacterial vaginosis, Metronidazole 500mg 1 tab Cervix: 4.04x4.03x6.36cm
treatment completed every 12 hours for 14 days – TVS UTZ C/O OB SONO initial ES: 1.39cm r/o Acute Diverticulitis
(-) vaginal discharge COMPLETED (6/11/24) RO: 3.87x3.18x4.15cm
(-) vaginal pruritus There is a tubular structure noted at the right adnexa measuring 6.97x4.20x6.90cm Surgery Notes (6/16)
LO: 4.80x2.60x4.21cm Noted official WAB CT scan result
WAB CT Scan (06/14, OSMAK) Dr. Cuevas updated
Pelvic inflammatory disease Doxycycline 100mg/tab every CLINICAL DATA: patient was last seen at the OB ER on May 31, 2024, managed as a case of G3P2 (2012) 7 weeks Respectfully signing out
(-) LLQ pain 12 hours for 14 days AOG, COMPLETE ABORTION, who presented with hypogastric and left lower quadrant pain on June 11; t/c pelvic
(-) hypogastric pain COMPLETED inflammatory disease; rule out acute diverticulitis OB wise
(-) febrile episodes SHIFT Cefoxitin 2gm TIV (-) Still for discharge (philhealth)
(-) dysuria ANST every 6 hours to COMPARISON: none; Ultrasound dated May 31, 2024 was correlated. For repeat TVS UTZ after 2 weeks
(-) foul-smelling vaginal Cefuroxime 500 mg/tab 1 tab TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained with oral, rectal and intravenous Ffup at OB OPD on June 27,2024
discharge BID for 7 days contrast. Pad counting qshift
FINDINGS: Daily body and perineal hygiene
There is a heterogeneously enhancing, lobulated focus in the left adnexa closely related to the uterine fundus, WOF profuse vaginal bleeding,
r/o Acute Diverticulitis measuring 7.7 x 10.7 x 9.7 cm (ApxWxCC). There is slight superior displacement of the distal descending colon. severe hypogastric pain
(-) abdominal pain No meds for now The right fallopian tube is tortuous and dilated. The uterus is enlarged with a volume of 189 ml (6.9 x 6.9 x 7.6
(-) difficulty defecating cm), likely related to recent gravidity.
(-) febrile episodes The ovaries cannot be delineated in this study.
The liver is not enlarged with smooth contour. Intrahepatic ducts are not dilated. Portal vein is patent.
OB wise The normal-sized gallbladder exhibits no abnormal intraluminal densities. Wall is not thickened. Common duct is
No profuse vaginal bleeding Paracetamol 600mg TIV every not dilated.
No severe hypogastric pain 6 hours as needed for The pancreas is normal in size and configuration. Pancreatic duct is not dilated.
abdominal pain The spleen and adrenal glands are normal without undue enhancement.
LMP: April 8, 2024 Both kidneys are normal in size and exhibit prompt and bilateral nephrogram. No evidence of hydronephrosis or
opaque lithiasis. Ureters are not dilated.
Abdomen soft flabby, non The urinary bladder is adequately distended without intraluminal filling defects.
tender The included esophagus, stomach and intestinal segments are grossly normal. The appendix is not dilated.
Negative enlarged lymph nodes. Minimal fluid collection is noted in the bilateral paracolic gutters.
IE: cervix closed, (-) cervical Small sclerotic foci are seen in the left femoral head, likely bone islands.
motion tenderness, uterus The included lung bases are clear.
not enlarged, (-) palpated
adnexal mass, (-) adnexal Impression:
tenderness, left - Heterogeneously enhancing left adnexal focus, likely representing the tubo-ovarian abscess. Correlate with
ultrasound findings
RVE: no skin tags, no anal - Right hydrosalpinx
fissures, good sphincteric - Post gravid uterine enlargement
tone, no mass, free - Minimal ascites
parametria, no blood per Findings:
examining finger Uterus is anteverted and enlarged measuring 8.1 x 6.8 x 6.6 cm (volume of 189 mL).
Myometrial echopattern is homogeneous.
No focal mass is seen.
Endometrial lining is not thickened measuring 1.1 cm.
There is a tubular structure arising from the right adnexa with internal low level floating echoes. Inferior to it is a
normal-sized right ovary measuring 1.4 x 1.4 x 1.3 cm (volume of 1.2 mL).
Another tubular structure is noted, arising from the left adnexa with internal low to medium floating echoes. The
TVS UTZ, OSMAK, MAY 31, 2024
left ovary is enlarged and seen adjacent measuring 4.5 x 5 x 2.1 cm (volume of 24.6 mL).
The cervix is normal in size measuring 4 x 2.6 x 3.7 cm. No focal lesion identified.
Fluid collections are seen in the perihepatic, perisplenic and pelvic spaces.
Impression:
Findings suggestive of bilateral tubo-ovarian complexes. Cannot entirely rule out ectopic pregnancy.
Enlarged anteverted uterus with non-thickened endometrium
Unremarkable sonogram of the cervix
Ascites
Enlarged uterus 8.61 x 7.32 x 9.32 cm
Thickened endo (3.76 cm) with minimal color flow (Color score 2)
NO GS at the time of exam
RO 2.97 x 2.02 x 2.55 cm with follicles less than 10mm
Right adnexa superior and lateral to the RO is an elongated cystic mass with complete and incomplete septations
6.99 x 5.20 x 7.23 containing sonolucent fluid, consider hydrosalpinx
TVS UTZ c/o OB sono (05/27,
LO 2.99 x 1.61 x 2.24 with follicles less than 10mm
Balbido’s)
Impression:
Enlarged uterus
Thickened endometrium
Consider retained products of conception
Normal sized ovaries
Right adnexal mass consider hydrosalpinx
OB 13 G3P2 (1011) Pregnancy Uterine BP 90/60 Soft diet to full diet CBC/PC n/a
MAHINAY, KIMBERLLY 21 1/7 weeks AOG by PR 80 IVF: D5LR 1L x KVO Date Hgb Hct WBC S L M E Plt
FELIZARIO ultrasound breech in threatened RR 20 Isoxsuprine drip – to consume 06/14 10.8 0.31 9.8 72 17 8 3 318
26 preterm labor T 36.6 then d/c 06/07 12.0 0.35 11.9 76 13 9 2 362
YC Acute appendicitis O+/HbsAg NR/RPR NR
I: 3390 Urinalysis
3771333 s/p Appendectomy, s/p Failed O: 2400
06/14/24 Non operative treatment for
06/15 NEG TRACE 1.4 2.7 17.7 2.9
Dr. Odevilas/ Tungcul, acute appendicitis (06/16/2024) Ht: 149.8 cm
06/07 NEG NEG 1.2 2.0 20.6 24.8
Ballesteros, De Paz/ Gavino(TL)/ Day 2 Wt: 40kg
Gauiran, Pesigan/ Jasarino, Vit BMI: 18.02 kg/m2 Coagulation studies
O Date PT % Activity INR APTT
06/14 11.7 103.3 1.04 33.5
2159H/ 2250H Chemistry
Minimal Date Crea Na K
06/15 41.30 135.19 3.55
Acute appendicitis SHIFT Cefoxitin 2g IV loading Ferritin (06/07, OsMak): 14.40 Acute appendicitis
(-) fever dose then 1g IV every 8 hours HbA1c (06/07/24): 5.01% Continue antibiotic treatment
(-) recurrence of vomiting to Cefuroxime 500 mg/tab 1 Vaginal discharge KOH (06/07/24) NEGATIVE Pelvic MRI was deferred
(-) RLQ direct and rebound tab BID Vaginal discharge GS (06/07/24) MEAR SHOWS PREDOMINANCE OF GRAM POSITIVE LACTOBACILLI WITH MANY EPITHELIAL CELLS AND FEW LEUKOCYTES
tenderness Paracetamol 500 mg/tab 1 Imaging Surgery (06/17/24)
(-) vomiting tab every 4 hours Pelvic + Focused RLQ UTZ SLIUP varying lie, 15 weeks and 4 days; EFW 132 grams. FHT 146 beats/minute; Placenta maturity is grade 0 located at the May have soft diet to full diet
(06/14/24, OSMAK) initial anterior upper portion of the uterus; SDP 3.07 cm Dec IVF to KVO
c/o Dr. San Pedro RLQ Findings: Shift IV meds to oral
Scanning of the right lower quadrant shows fecal filled bowel segments. 1. Cefuroxime 500 mg/tab 1 tab
The visualized appendix is non-compressible measuring 0.5 cm in its maximum diameter. Few appendicoliths are identified with BID
sizes ranging from 0.3 cm to 0.4 cm. Periappendiceal fluid is evident. 2. Paracetamol 500 mg/tab 1 tab
OB Wise Multivitamins 500mg/tab, 1 No solid, cystic, or complex lesion identified. every 4 hours
No hypogastric pain tab once a day Impression: Acute appendicitis with appendicoliths COD done
No vaginal bleeding Ferrous sulfate 325mg/tab, 1 Pelvic + focused UTZ SLIUP, variable presentation, 106g, 150bpm, Anterior grade 0 placenta, SVP 4.1cm Encourage early ambulation
(+) Flatus tab twice a day (06/07/24, OSMAK) The uterus is anteverted and measures 11.6 x 9.3 x 10.6 cm. The cervix is closed and normal in size measuring 3.9 x 4.4 x 4.8 For possible discharge tom GS
(+) BM Calcium carbonate cm. wise
500mg/tab,1 tab twice a day The right ovary is normal in size measuring 2.3 x 1.7 x 1.7 cm (volume of 3.4 ml).
G3P2 (1011) The left ovary is likewise normal in size measuring 3.8 x 1.8 x 2.8 cm (volume of 10.2 ml)
LMP: February 20,2024 OB Wise
AOG: No posterior-cul-de-sac fluid noted to the extent visualized. For COD today
16w6d AOG by LMP RLQ Findings: Monitor FHT q4h
21w2d AOG by UTZ Fecal filled bowel segments are seen in the right lower quadrant and bilateral adnexal regions precluding adequate evaluation. Monitor VS q4 I&O qshift
(UTZ: 03/11, 7w) Appendix is not visualized. WOF: severe hypogastric pain,
No complex masses or abnormal fluid collections to the extent visualized. profuse vaginal bleeding,
Slightly globular, nontender Intraoperative Findings: regularly uterine contractions,
FHT: 140s Appendix 5cm x 0.7cm, in suppurative state w/ engorged vessels, oriented posterior to ileocecal junction. Distal half thicker than proximal half. No perforations febrile episode, vomiting, severe
IE: cervix closed noted abdominal pain
EBL: Minimal
OB 16 G2P1(1001) PU 12 4/7 weeks BP 110/70 NPO CBC with PC

MAGAMAY, NOREEN MAE AOG HR 74 IVF: D5LR 1 L x 30 gtts/min Date Hgb Hct WBC S L M E Plt
BALAUT Multiple Electrolyte Imbalance RR 20 IVF: KCl drip: 20 meqs in 80 cc
06/16 12.2 0.35 14.7 70 24 6 367
30 (Hyponatremia, Hypokalemia) T 36.8 PNSS every 4 hours x 5 cycles
NYC secondary to acute GI losses, – completed 06/17 B+/NR
corrected I: 1347 Urinalysis
3868842 Hyperemesis gravidarum O: 1300 Date Sugar Protein WBC RBC Epithelial Bacteria
06/16/24 Urinary Tract Infection 06/16 NEG 1+ 9.6 H 31.9 H 22.1 692.3 H
Dr. Ordono/ Tungcul/ 06/16 NEG NEG 15.1 H 1.0 78.2 H 2024.7 H
Gavino(TL)/ Gauiran Gallano/ Multiple Electrolyte No oral meds for now Chemistry
Alzaga Tiongson Imbalance (Hyponatremia, Date BUN Crea AST ALT Potassium Sodium Chloride Multiple Electrolyte Imbalance
Hypokalemia) secondary to 06/17 4.49 (Hyponatremia, Hypokalemia)
acute GI losses, corrected 06/16 3.59 48.47 15.28 12.03 3.15 L 135.20 L 102.07 secondary to acute GI losses,
(-) body weakness Imaging corrected
(-) leg pain TVS UTZ (06/16 OSMAK) SLIUP, cephalic 12 weeks 3 days Grade 0 posterior 56g, 177-180bpm; SDP 2.29
(-) chest pain IM Nephro (06/17)
referred to Dr. Ogbac
START KCl drip: 20 meqs in 80 cc
PNSS every 4 Hours x 5 cycles
repeat K post correction
suggest to start Ceftriaxone 2g
TIV OD for consideration of UTI
Hyperemesis gravidarum Metoclopromide 1amp TIBV

Hyperemesis gravidarum
(-) projectile vomiting every 8 hours as needed for
Continue present medications
(-) dehydration vomiting
and management
(+) intermittent epigastric Nausecare tab, 1 tab once a
pain PS 2/10 day once diet is resumed
Last Vomit: Pantoprazole 40 mg TIV OD
06/18/24 0400H amounting
to 1/3 cup, no blood
Urinary Tract Infection
For repeat UA on the 3rd day of
antibiotic
TSR Urine CS (06/17)
Urinary Tract Infection Ceftriaxone 2gm TIV () ANST
(-) dysuria OD
IM Nephro (06/17)
(-) hematuria
suggest to start Ceftriaxone 2g
(-) fever
TIV OD for consideration of UTI
OB Wise Folic acid 10 mg/tab 1 tab OD OB Wise

no profuse vaginal bleeding Calcium 500 mg/tab 1 tab BID For electrolyte imbalance
no passage of meaty material Multivitamins 500 mg/tab 1 correction
tab OD FHT OD
G2P1(1001) VS q4
LMP: March 29, 2024 STRICT I and O qshift
AOG by LMP: 11w4d
12w4d (06/16; 12w3d)
abdomen flat soft nontender

FHT not appreciated
SE: cervix violaceous, no
lesions, no polyp, no bleeding
per os
IE: cervix closed,no CMT, no
AMT
OB 17 G2P2 (2002) Pregnancy Uterine BPR 140/70-90 DASH diet CBC with PC DMPA
DAYAPDAPAN, JENNELYN Delivered term, cephalic, live BP 140/80 IVF: PNSS 1L x 90 cc/hr Date Hgb Hct WBC S L M E Plt NICU for LBW
NILLAS baby girl MAP 146/76 IVF: MgSO4 drip –
06/17 12.5 0.36 18 85 10 5 91 L
36 AS 9,9 BW 1.79 kg BL 43 cm MI HR 83 (completed 06/17)
YC 38 weeks SGA RR 20 (+) IFC 06/17 13.1 0.38 17.5 81 12 7 70 L
Pre-eclampsia with severe T 36.8 06/16 14.3 0.42 29.4 89 6 5 185
06/16/2024 features 06/16 13.0 0.38 18.5 71 21 7 1 237
3932513 Complete HELLP syndrome
O+/NR
Dr. Canaveral/Tungcul, Go/ Gestational Diabetes Mellitus, None for now
Urinalysis
Reyes (TL), Roque (p) /Posadas, diet controlled Gestational Diabetes Gestational Diabetes Mellitus,
Tugado/Kadappurath Elderly Gravid Mellitus, diet controlled diet controlled
No polydipsia 06/16 NEG 2+ 2.0 36.3 8.4 4.6 CBG TIDACHS
By Normal Spontaneous No polyuria Chemistry For 75g OGTT after 4-12 weeks
Delivery; Right Mediolateral No polyphagia AST ALT BUA Na K CL Total Direct Indirect post-partum
Date BUN Crea LDH Amylase
Episiotomy with repair under Bilirubin Bilirubin Bilirubin
local anesthesia (06/16/2024) 2041.12 194.58 159.89
06/18 53.98 84.86
H Complete HELLP syndrome
Complete HELLP syndrome Dexamethasone 10mg TIV 2147.48 275.73 175.32 135.73 19.28 8.04 H 11.24 For daily CBC and AST ALT LDH,
06/17 58.89
G2P2 (2002); S/P NSD with (-) gum bleeding every 12 hours (D1) H H H creatinine
RMLE Day 2 (-) headache 2534.86 536.55 213.13 128.10 3.93 99.19 For Dexamethasone 10mg ITV
06/17 57.74
Gestational Diabetes Mellitus, (-) chest pain H H H L every 12 hours until platelet is
diet controlled (-) DOB/ SOB 294.23 168.85 358.77 >100,000
06/16 2.53 52.28 927.28
Pre-eclampsia with severe H H
features 06/16/24 2200H gum IM Hema (06/17)
Elderly Gravid bleeding Stat CBC Coagulation studies Dx: CBC monitoring as ordered
Tranexamic Acid 1gm Date PT % Activity INR APTT every 12 hours to include PBS on
06/17 12.1 100 1.08 30.3 next extraction
Clotting Time; 3 Tx:
Bleeding Time: 2 STANDBY Tranexamic acid 1 500
Tronponin I (06/16/24)– 0.23 mg TIV q8 for bleeding (gum
Pre-eclampsia with severe Nifedipine 30mg tab OD ECG (06/16/24)– - Normal Sinus Rhythm bleeding, epistaxis, melena, etc)
features Hydralazine 5mg TIV now Ferritin (06/15) 191.40 H Relay to duty MROD once with
(-) dizziness then 10mg 75g OGTT (March 16 2024) at 26 weeks repeat CBC and other workups
(-) headache TIV q30min PRN for BP OGTT 77.14
(-) blurring of vision >=160/100 1hr OGTT 182.99 H IM Gastro (06/17)
(-) epigastric pain (Max of 25mg/24 hrs) 2hr OGTT 150 DX: AST,ALT monitoring as
For MgSo4 drip completion CBG monitoring ordered to include lipid profile –
06/16/24 1300H (+) MgSO4 4g LD Date 0500H 1100H 1700H 2100H done
Epigastric pain with acid 06/17 160 155 134 113 Tx:
reflux ECG (NSR), Troponin I START essential phospholipid 2
170 127 120 111
(0.23) 06/16 caps 3x/day if ok with main
139
Omeprazole 40mg TIV service
given relieved WOF: epigastric pain, RUQ pain
Last episode of BP elevation: IM Nephro (06/17)

06/16, 140/80, 170/100 Continue IVF: D5LR 1L x KVO
H5, MgSO4 LD (06/16, Dx: include Na on subsequent
0900H) Cefuroxime 500mg/tab 1 monitoring – done
tablet every 12 hours to
OB wise complete for 7 days
No profuse vaginal bleeding Paracetamol + Tramadol
No severe hypogastric pain 325/37.5mg/tab, 1 tab every Pre-eclampsia with severe
8 hours as needed for pain features
Ferrous sulfate 325mg/tab 1 For BP monitoring and record
tablet 2x/day Ongoing 24 hr urine protein
Tranexamic acid 1 500 mg TIV collection (TE: 06/18 0730H)
q8 for bleeding
OB wise
and management
For assessment every 4 hours c/o
OB ROD
[ ] For lipid profile 06/18

[ ] Still for Amylase – for send out,
patient is amenable, for
canvassing
OB 23 G3P2 (2002) Pregnancy Uterine BPR 100-110/60-70 LSLF diet with SAP CBC/PC n/a
CABUENAS, JENELYN ABEÑON 29 3/7 weeks AOG by LMP BP 110/70 Heplock Date Hgb Hct WBC S L M E Plt
32 transverse not in labor HR 80 06/11 11.9 0.34 12.7 82 13 5 - 245
YC Intrauterine growth restriction RR 20 *1u pRBC secured c/o Maam
Deep Vein Thrombosis T 36.8 05/30 13.0 0.38 74 18 7 1 - 276 Sarah
286599 Chronic Hypertension 05/11 12.0 0.35 9.5 74 15 9 2 278
04/24/24 Chronic Active Hepatitis B I: 1300 05/08 11.1 0.32 11.1 67 25 7 1 269 Chronic Hypertension
Dr. Palomares, Castro/Tungcul, infection, high infectivity O: 1050
05/04 11.7 0.33 9.7 64 24 9 1 281 For BP monitoring and control
Ballesteros, De Paz (TL) / Hepatitis A infection
Gauiran, Posadas, Myoma Uteri Chronic Hypertension Methyldopa 250mg 1 tab BID 04/29 12.2 0.36 9.3 75 16 6 3 280
Deep Vein Thrombosis
Gallano*/Alzaga, Kadappurath t/c Anxiety disorder (-) BOV ISDN 5mg/tab, 1 tab SL as 04/20 11.2 0.34 9.0 67 24 7 2 277
Well’s score 5
Vaginal Candidiasis, resolved (-) headache needed for chest pain B+/R
VTE score 1
(-) dizziness Urinalysis
IM Cardio 06/17/2024
(-) chest pain Date Sugar Protein WBC RBC Epithelial Bacteria Continue Enoxaparin 8000units
(-) DOB/SOB
05/11 Neg Neg 0-2 0-2 Mod Rare SQ BID
(-) vomiting
05/03 neg neg 0.9 0.4 13.7 27.7 Compression stockings 12hrs on
and 12 hours off
Deep Vein Thrombosis Enoxaparin 8000 units SC 2x a 04/29 Neg Neg 2.1 0.9 26.5 40.9
Well’s score 5 day 04/24 Neg Neg 3.1 0.5 51.2 233.1 H Surgery (06/12/24)
VTE score 1 Chemistry: Continue present management
(+) swelling of the leg and
Date BUN BUA Crea Na K T Ca Mg AST ALT Trop I FBS HBA1c Provide adequate analgesia
thigh, left
Still for IVC filter insertion at
(-) direct tenderness 06/11 2.43 43.76 133.62 L 3.90 12.20 15.45
institution of choice (PGH)
(-) warm to touch, left leg 46.22 134.97 L 4.05 0.80
05/30 2.27 No active management TCVS-
(-) red/discoloration on the
05/15 2.62 46.02 134.63L 3.9 0.73 wise, respectfully signing out
affected leg
Refer back as needed
(-) shortness of breathing 05/08 2.61 45.74
(-) pain on deep breathing
05/05 75.06 4.94 IM Vascular (06/14/2024)
(-) pain/tenderness on the
Continue Enoxaparin 8000 units
affected leg when 04/29 2.76 50.52 131.9 L 3.93 2.34 0.68
SC 2x a day
standing/walking
04/20 2.25 325.07 46.27 10.58 12.59 0.37 Continue application of
(-) sensory loss
Coagulation studies compression stockings (12 hours
(+) good lower extremity
on, 12 hours off)
pulses (posterior popliteal, Date PT % Activity INR APTT
Refer accordingly
posterior tibial, dorsalis pedis 06/10 12.0 100.8 1.07 27.3
2+)
05/08 12.0 100.8 1.07 26.3 Anesthesiology notes (06/09)
04/20 11.7 103.3 1.04 24.9 L Referred last night at 6pm via
D-dimer (03/01/24): >3000 (H) phone call by Dr. Pesigan
Hepatitis profile (04/05/24) No clinical referral sheet as of
now, still awaiting
HbsAg REACTIVE
Noted history and labs
Anti-HAV REACTIVE Please secure 1u pRBC properly
Anti-HAV IgM NONREACTIVE typed and crossmatched and 1u
Anti-HCV NONREACTIVE pRBC as standby for possible OR
use
Anti-HBc IgG REACTIVE
Please secure second IV line on
Anti-HBc IgM NONREACTIVE contralateral arm then heplock if
HbeAg REACTIVE for OR
Anti-HBs NONREACTIVE Please discontinue enoxaparin 24
hours prior to OR
Anti-Hbe NONREACTIVE
**Referred back to Dr Dalmacion
Chronic Active Hepatitis B No meds for now 12L ECG (clinical referral given) –
infection, high infectivity 04/26 Normal sinus rhythm previously attached to chart
Hepatitis A infection
04/23 Normal sinus rhythm
(-) icteric sclerae/jaundice
Vaginal GS/KOH 05/03/2024: Positive; Chronic Active Hepatitis B
(-) abdominal pain
Vaginal GS/KOH 05/03/2024 SMEAR SHOWS PREDOMINANCE OF GRAM POSITIVE LACTOBACILLI WITH MANY LEUKOCYTES, MANY EPITHELIAL CELLS AND infection, high infectivity
known Hep B since 2011
PRESENCE OF FUNGAL ELEMENTS Hepatitis A infection
Imaging For HBV DNA viral load c/o
BPS + Doppler SLIUP, transverse, 26 weeks and 6 days; 969g , 132bpm outside institution -refused,
velocimetry Adequate amniotic fluid volume, 6.33cm waiver secured
(06/14/24) Fundal, grade II placenta
The estimated fetal weight is less than 2nd percentile (Hadlock) and less than the 10th by Colorado, findings suggestive of fetal growth GASTRO 04/25/2024
restriction. Known to service from previous
CPR: 1.956 admission
The doppler velocimetry showed normal indices of UMA and MCA with CPR >1 (1.956), suggestive of adequate fetomaternal perfusion. Still for HBV DNA
BPS: 8/8 No medications for now
Contact precaution
Pelvic UTZ c/o SLIUP, 25w2d, Breech, 127bpm,SDP: 5.69, 777g, Fundal Grade II placenta
OB Sono Impression: No active gastro management,
respectfully signing out of this
(06/03/24) *Estimated fetal weight is below the 10th percentile of the established gestational age, suggest serial growth monitoring.
t/c Anxiety disorder case
*Fetal face cannot be fully assessed due to unfavorable fetal position
(-) difficulty of sleeping Refer back once with HBV DNA
(-) palpitation None for now Venous duplex Vein diameter (cm): Left result
(-) DOB Scan Greater saphenous vein (above knee): 0.22 Thank you
(-) chest pain (05/31/24 Greater saphenous vein (below knee): 0.19
05/11 0830H DOB (no OSMAK) Greater saphenous vein (ankle): 0.15 t/c Anxiety disorder
triggering factors) Lesser saphenous vein: 0.26 MHU (06/12)
Saphenofemoral junction: 1.31 Patient comfortable, no pain at
Vaginal Candidiasis, resolved The left common femoral vein, superficial femoral vein, deep femoral vein and popliteal veins are now partially compressible. The left the moment
(-) white frothy discharge saphenofemoral junction and greater saphenous vein are now compressible with intraluminal medium level echoes. The left posterior tibial Continue management
(-) perceived uterine and peroneal veins are now compressible.
contractions Metronidazole + Miconazole No significant varicosities seen.
(-) foul smelling discharge 750/200mcg/tab, 1 tab once The lesser saphenous vein again has thickened walls with calcifications. Vaginal Candidiasis, resolved
a day before bedtime The previously noted cobblestoning along the subcutaneous region of the popliteal region extending to the ankle is no longer evident. No active management
OB wise (completed 05/13) Impression
Good fetal movement - Interval regression of findings suggestive of venous thrombosis, as detailed above. OB wise
(-) perceived uterine - Unchanged thickened wall with calcifications, left lesser saphenous vein. Definitive plan:
contractions - Resolution of subcutaneous edema, popliteal down to the ankle region For readmission to PGH at 36
(-) watery/bloody vaginal Multivitamins + amino acid CAS (05/13 SLIUP, 22w4d, breech, AHL grade I, 150bpm, SDP 2.89cm, 547g weeks for possible IVC filter
discharge tab 1 tab 2x daily OSMAK) The estimated fetal weight is below the 10th percentile of the established gestational age, suggest serial growth monitoring. insertion (for reassessment if still
Ferrous sulfate 325mg/tab 1 Limited congenital anomaly scan showed no gross congenital anomaly seen at the time of scan (Face not fully assessed due to unfavorable warranted)
G3P2 (2002) tab twice a day fetal position); Suggest re-evaluation of the fetal face. For vacuum delivery, but for
LMP: November 25, 2023 Calcium 500mg/tab 1 tab 2x a Chest xray No significant chest findings delivery anytime if with
AOG: day (05/11) fetomaternal indication such as
29 3/7 weeks by LMP Dexamethasone 6mg TIM recurrent severe hypertension,
Pelvic UTZ SLIUP, Breech presentation, 20 2/7 weeks AOG by BPD, 137bpm, 340g, AFI: 4.54cm, SDP: 4.54cm, Posterior High Lying gr 0
28 5/7 weeks (02/14; 10w6d) every TIM for 4 doses- progressive renal insufficiency,
(04/24)
completed(06/10) persistent thrombocytopenia,
FH 26cm Nifedipine 10mg/tab, TID for Pelvic UTZ SLIUP cephalic 17w1d 174 g 147 bpm SDP 3.8 cm AHL gr 1 pulmonary edema, eclampsia,
FHT: 140 bpm 48 hours – completed (04/01) suspected abruptio placenta,
IE: cervix closed, uterus Isoxuprine 10mg/tab, 1 tab Chest xray no active parenchymal opacities in both lungs. severe fetal growth restriction,
enlarged to AOG every 8 hours x7 days- (04/04) Pulmonary vascular markings are within normal limits. BPS 4/10 or less on at least 2
completed The heart is not enlarged. occasional 6 hours apart,
Both hemidiaphragms and costophrenic angles are intact. recurrent variable or late
Bony thorax is unremarkable. decelerations
Impression: No significant chest findings For NST BID
Venous duplex The left common femoral and proximal superficial femoral, visualized deep femoral, as well as the popliteal, posterior tibial and peroneal Monitor vsq4, FHTq6 and record
Scan veins are non-compressible now with intraluminal hyperechoic component and with absent color flow upon Doppler interrogation. The left Apply compression stockings at
(03/23/24) saphenofemoral junction and proximal greater saphenous vein are now also non-compressible and with intraluminal hyperechoic foci and all times
with absent color Doppler flow. PROD informed (Dr. Calacday)
The rest of the greater saphenous vein is non-dilated and compressible. No significant varicosities seen. AROD informed (Dr. Concepcion)
The lesser saphenous vein again has thickened walls with calcifications. WOF: severe hypogastric pain,
There is further decrease in the degree of cobblestoning of the subcutaneous region of the popliteal region down to the ankle. profuse vaginal bleeding, chest
Impression: pain, DOB/SOB, decreased fetal
- Interval evolution of findings suggestive of venous thrombosis, as detailed above. movement
- Thickened wall with calcifications, left lesser saphenous vein. Please measure calf
- Regression of subcutaneous edema, popliteal down to the ankle region circumference, thigh
circumference daily and record
Pelvic UTZ SLIUP, cephalic, 15w2d, AHL, G0, SDP 3.32cm, 118g, ; A hypoechoic focus is seen in the posterior wall of the uterus measuring 5.05 x 7.12 x
(03/16/2024) 6.03 cm, consider myoma uteri
Perinatology notes (06/15/24)
Venous duplex The left common femoral and entire superficial femoral and visualized deep femoral veins, as well as the popliteal, posterior tibial and Case referred back to
Scan peroneal veins are non-compressible with absent color flow upon Doppler interrogation. The proximal segment of the left saphenous vein is Perinatology service (dr. Castro)
(03/09/24) partially to non-compressible with thickened walls. Wall calcifications are seen in the lesser saphenous veins. LSLF diet
There is also no noted vascular flow in the visualized left external iliac vein. Heplock
The greater saphenous vein is non-dilated and compressible. No significant varicosities seen. No significant venous blood flow reflux seen Meds:
on maneuvers. 1. Continue Enoxaparin 80000 u
There are unenlarged left inguinal lymph nodes with intact fatty hila. SC BID
There is cobble stoning of the subcutaneous region of the proximal left thigh down to the distal leg. 2.Continue present medications
- Consider venous-occlusive disease or thrombosis, left common femoral, entire superficial femoral, visualized deep femoral, popliteal, Daily body and perineal hygiene
posterior tibial, peroneal and proximal lesser saphenous veins. Monitor VS every 4 hours I and O
- Consider venous-occlusive disease or thrombosis, left external iliac vein. every shift
- Wall calcifications, left lesser saphenous vein. Continue compression stockings
- Subcutaneous edema, proximal left thigh down to the distal leg 12 hours on and 12 hours off
- Unenlarged left inguinal lymph nodes NST BID
WOF: decrease fetal movement,
TVS UTZ Uterus is anteverted and enlarged measuring 9.63 x 8.79 x 1.67 cm. Myometrial echopattern is homogeneous. A hypoechoic focus
watery or bloody vaginal
(2/14/24, emanating posterior shadowing is noted in the posterior wall measuring 7.19 x 4.60 x 4.79 cm (FIGO 5: subserosal; ≥ 50% intramural)
OSMAK) There is a gestational sac measuring 5.25 x 6.58 x 2.52 with mean sac diameter measuring 4.78 compatible with 10 weeks and 2 days age of discharge, perceived
contractions, headache, nausea
gestation. Within is a single embryo with a crown-rump length of 4.01 cm compatible with 10 weeks and 6 days age of gestation. Good
and vomiting
cardiac activity noted at 171 beats/min.
There is no subchorionic hemorrhage.
Pending labs:
Cervix is long and closed measuring 4.37 x 4.55 x 3.65 cm with no demonstrable lesions.
[ ] For 2D echo at Makatilife on
The right ovary is normal in size measuring 4.38 x 1.73 x 3.15 cm (volume of 12.54 mL). A cystic focus is seen without surrounding
July 9,2024
vasculature measuring 1.27 x 1.14 x 1.51 cm.
[ ] Pelvic ultrasound (06/28)
The left ovary is obscured by bowel gas.
[ ] Ideally for 75g OGTT at 24-28
No definite lesion in both adnexa.
weeks - GA not amenable since
No definite evidence of fluid seen in the posterior cul-de-sac.
IMPRESSION: the patient is admitted
[x] HBV DNA-refused
Single live intrauterine pregnancy compatible with 10 weeks and 6 days age of gestation by crown-rump length.
[ ] To retrieve duplex scan result
EDD: September 5, 2024
done at PGH
Unremarkable sonogram of the cervix.
Normal-sized right ovary with physiologic cyst. Non-visualized left ovary
*Still processing aid from other
No evident posterior cul-de-sac fluid.
government institution for
guarantee letter
Tracing
DSWD P5000
Date Interpretation BFHT Variability Acceleration Deceleration Contraction PCSO-rejected
06/18 AM Reactive 135-140 Moderate (+) (-) No contraction Office of VP- awaiting
06/17 PM Reactive 135-140 Moderate (+) (-) No contraction Bong Go- not available,
Enoxaparin
06/17 AM Reactive 135-140 Moderate (+) (-) No contraction
06/16 PM Reactive 140-145 Moderate (+) (-) No contraction
06/16 AM Reactive 130-135 Moderate (+) (-) No contractions
06/15 PM Reactive 135-140 Moderate (+) (-) No contractions
Mid-Calf, R Mid-Thigh, R Mid-Calf, L Mid-Thigh, L

06/17 38 59 39 59
06/16 38 59 39 58
06/15 38 57 39 59
06/14 39 59 39 59
06/13 39 60 39 58
06/12 39 59 39 59
06/11 39 59 39 59
06/10 40 63 39 60
06/09 40 64 39 60
06/08 40 64 39 61
06/07 39 59 40 60
06/06 40 59 39 60
06/05 37 61 40 60
06/04 37 62 39 63
06/03 37 62 38 63
06/02 37 63 38 63
HR 5 G1P1 (1001) Pregnancy Uterine BPR 100-110/60-70 DASH diet CBC with PC NICU for
DEMAIN, RIZZA MAE CAHIMAT Delivered term cephalic BP 110/60 IVF: heplock, limit fluid intake Date Hgb Hct WBC S L M E Plt maternal
20 Live baby boy HRR 89-105 to 750 ml 06/1 illness
NYC AS 9,9 BW 2.34 kg BL 44 cm MI HR 89 Limit oral fluid intake to <750 10.7 0.32 20.9 H 88 H 6 5 1 246 (Gravidocardiac
5
38 weeks AGA RR 32 (30-36) m/day secondary to
06/1
316822 Gravidocardiac secondary to T 36.9 (+) cardiac monitor 10.7 0.32 12.7 79 14 6 1 249 Rheumatic
3
06/12/2024 Rheumatic Heart Disease Mitral O2 sat 95% at room air (+) IFC Heart Disease
06/1
Dr. Calo/Tungcul, Go/Roque Regurgitation, severe NYHA II 11.9 0.36 12.5 83 11 5 1 270 Mitral
2
(patho), Reyes(TL)/Posadas, WHO II I 590 Regurgitation,
06/1
Tugado/ Kadappurath Hospital acquired pneumonia O 2100 11.3 0.35 13.2 76 17 5 2 241 severe NYHA II
2
Hypokalemia secondary to poor WHO II)
1825H/1916H oral intake, corrected O+/NR FP: IUD
EBL 700 cc Urinalysis
By Emergency LTCS I with IUD Date Sugar Protein WBC RBC Epithelial Bacteria Leukocyte
insertion under GETA for 06/15 Neg Trace 0.5 6.9 10.8 7.1 Neg
maternal illness (impending 06/12 Neg Neg 0.9 0.8 18.9 2.7 Neg
respiratory failure secondary to Gravidocardiac secondary to Chemistry
Carvedilol 25mg/tab 1 tab 2x
pulmonary congestion Rheumatic Heart Disease Date RBS BUN BUA Crea AST ALT Alk phos Trop I Na K Cl Albumin
a day
secondary to heart failure) Mitral Regurgitation, severe 06/17 3.52
Furosemide 40 mg TIV once a
(6/12/24) NYHA II WHO II 06/16 6.82 43.87 L 133.10 L 3.40 L 35.18
day
(-) shortness of breath 06/12 4.25 2.87 371.38 H 40.11 L 18.94 10.18 223.50 H 0.65 H 135.80 L 3.89 104.85
Benzathine penicillin G 1.2M
(-) chest pain Coagulation studies
units IM every 21 days –
G1P1 (1001) s/p LTCS I with IUD (-) palpitations Date PT %activity INR aPTT Gravidocardiac secondary to
given next dose: July 4
insertion under GETA for (-) cough 06/12 12.1 100 1.08 27.6 L Rheumatic Heart Disease Mitral
maternal illness (impending Symmetrical chest expansion Ferritin (6/12/24 OSMAK): 66.40 Regurgitation, severe NYHA II
respiratory failure secondary to 12L ECG(06/12): Sinus tachycardia, t wave inversion on lead VI, nonspecific twave changes in lead III WHO II
pulmonary congestion Last episode of desaturation: Sputum CS (06/15/2024): SMEAR SHOWS FEW GRAM NEGATIVE BACILLI WITH FEW LEUKOCYTES AND OCCASIONAL EPITHELIAL CELLS. IM Cardio Notes (06/17)
secondary to heart failure) 6/15 2330H 75%  5LPM via COVID RAT (6/15): Negative Defer previous suggestion of 2D
Day 6 FM, high back rest  99% Thyoid function test (06/13, OsMak) echo
Gravidocardiac secondary to Referred to IM Cardio Since pt already had one done
TSH 2.00
Rheumatic Heart Disease Mitral last 06/03/24
FT3 2.42
Regurgitation, severe NYHA II Resume Furosemide 40 g TIV OD
Bactidol gargle 15mL for at FT4 0.90 L
WHO II Hospital acquired pneumonia next dose 06/18
least 45sec Imaging
t/c Community acquired (-) recurrence of febrile Continue Ceftazidime and
Ceftazidime 2g TIV every 12 Consider atelectasis versus consolidation pneumonia, right lower lung.
pneumonia – MR episode Carvedilol
hours (D2+1) Cardiomegaly with regression of pulmonary congestion and/or edema. Concomitant pneumonia cannot be
(+) decreased breath sound, CXR Official (06/15/24) Facilitate giving Ceftazidime
Paracetamol 300 mg IV every ruled out.
right lower lung O2 prn for dyspnea, desaturation
4 hours as needed for T > Unchanged subsegmental atelectasis, left lower lung
(+) occasional coughing < 94%
37.8 Follow-up was done on the same day (9:23 PM) now showing interval regression in the hazy opacities in both
episode
(-) crackles on right middle lungs and less accentuation of the pulmonary vascular markings. Other findings are unchanged
lung Post-op Chest xray (06/13 OSMAK) Impression: Hospital acquired pneumonia
(-) tachypnea Cardiomegaly Referred back to IM Pulmo (Dr.
Regression of pulmonary congestion. Concomitant pneumonia cannot be totally ruled out. Pagarigan) – ABG results
Last febrile episode Present study shows interval increase in the hazy opacities in both lungs.
06/18 2200H 38.0 -> Pulmonary vascular markings are now more accentuated. IM Pulmo (06/16/24)
Paracetamol 300 mg TIV -> The heart is magnified but appears enlarged. Give Furosemide 40 mg TIV now
Chest xray (06/13 OSMAK)
37.5 Both hemidiaphragms and costophrenic angles are intact. Maintain O2 support >94 and
Bony thorax is unremarkable. titrate accordingly
Impression: Continue Ceftazidime
Cardiomegaly with progression of pulmonary congestion. Concomitant pneumonia cannot be totally ruled out.
2D Echo EF: 65% Teicholz 65% Simpsons
(6/3/24) Rheumatic heart disease
Moderate mitral stenosis with severe mitral regurgitation IM Endo (6/15/24)
Thickened aortic valve Noted TFT
Pulmonic regurgitation Palpitations not endocrine in
Hypokalemia secondary to Eccentric left ventricular hypertrophy with good motion, normal contractility and preserved global systolic origin given TFT
poor oral intake, corrected KCl tab 750mg tab 2 tabs function Palpitations likely cardiac
(-) body weakness every 4 hours x 2 cycles – Dilated left atrium Signing out
(-) leg pain completed Low likelihood of pulmonary HTN
OB wise ABG Hypokalemia secondary to poor

No profuse vaginal bleeding Ferrous Sulfate 325mg/tab 1 HCO3 BE O2 sat O2 oral intake, corrected
No severe hypogastric pain tablet twice a day to pH pCO2 pO2 No active management
content
(+) flatus complete for 90 days 06/17 7.51 H 30 L 80 23,9 0.9 97 17.3
(+) BM Paracetamol + Tramadol 325
mg/37.5 mg/tab 1 tablet CBG monitoring OB wise
every 8 hours as needed for 0200 1800H 2000H Hook to cardiac monitor
pain Date 0000H 1600H Monitor VSq30min c/o OB ROD
H
Tranexamic Acid 1g TIV every Maintain O2 support
06/13 110 122 Discontinued
8 hours for 24 hours WOF: profuse vaginal bleeding,
06/12 85 79 129
Malunggay capsule 1 tab severe hypogastric pain,
once a day desaturation, DOB/SOB,
decreased sensorium
Perinatology Notes (06/17/24)

Noted desaturation episodes
yesterday
Still awaiting sputum CS result
Still for ABG – done
STRICT OFI 750cc/day
Continue present management
medications and monitoring
WOF profuse vaginal bleeding,
severe hypogastric pain,
desaturation episodes, sob, don,
hypotension
Pending
[ ] TSR Sputum GS/CS ( submitted
at OSMAK 6/15)
GYNE WARD
PATIENT INFORMATION DIAGNOSIS SUBJECTIVE/OBJECTIVE THERAPEUTICS LABORATORIES PLAN/NOTES
Gyne 1 Nulligravid BP 120/80 Clear liquids with SAP CBC with PC
ESCIETE, MARIAFE GARA Ovarian new growth, right PR 82 IVF: Sterofundin 1L x 100cc/hr *Endorsed patient by Dr. Binay
Date Hgb Hct WBC S L M E Plt
52 probably benign RR 20 (+) IFC *with reserved blood products c/o Dr.
NYC Ovarian Torsion, right T 37.2 06/17 12.1 0.36 27 H 92 H 4 4 211 Binay – 2 crossmatched c/o Maam Me-
Myoma Uteri ann available
06/11 s/p
06/04/24 Blood transfusion of 1u I: 2985 12.0 0.36 10.4 84 12 3 1 192 *secured waiver that specimen is for
BT 1upRBC
3931955 pRBC for anemia mild O: 2352 send out and is well explained to
Dr. Palomares/Tungcul, probably secondary to IJ output: 95 06/09 10.7 L 0.31 L 5.4 57 33 8 2 214 patient and relative
Go*/Reyes (TL)/Gallano, suboptimal intake, corrected
Gauiran/Kadappurath Hypokalemia secondary to 06/08 11.4 0.34 5.9 55 36 7 2 228
GI losses HT: 157cm
06/07 11.7 0.34 6.1 58 32 8 2 212
1308H/ 1528H Partial Gut Obstruction WT: 45kg
EBL 300 cc secondary to Intraabdominal BMI: 18.3 (underweight) 06/05 11.3 0.33 6.7 59 33 7 1 199
Abscess secondary to Grade
2 Rectal Injury 06/16/24 1900H Referred 06/04 12.6 0.37 9.7 70 23 7 0 258
for dec UO < 30cc/hr
s/p BT of 1u pRBC O+/NR
s/p Total Abdominal Anemia mild probably secondary to
Diphenhydramine 1am TIM Urinalysis
Hysterectomy, Bilateral Anemia mild probably suboptimal intake, corrected
prior to BT- given Date Sugar Protein WBC RBC Epithelial Bacteria
salpingoophorectomy under secondary to suboptimal s/p BT of 1u pRBC
06/05 NEG NEG 0.6 0.4 41.6 1.5
CLEA (06/10/2024) intake, corrected
Day 8 (-) pallor 06/04 NEG Trace 8.0 H 0.8 55.5 H 61.7 H
(-) dizziness Chemistry Hypokalemia secondary to GI losses
s/p Ultrasound-guided IJ (-) generalized body HbA1 Cl Mg Phos BUN ALB
Date BUA AST ALT Na K Crea
catheter insertion, Right weakness c Dr Violago updated
(06/17/2024) Pink palpebral conjunctiva 06/17 134.93 L 3.27 L 0.51 L 82.54 3.31 Please fast drip 300cc PLR
40mEq KCl in current IVF to run 06/16 137.32 4.17 0.67 84.42 5.17
s/p Emergency Exploratory Continue monitoring VS and UO Q1H
for 1 cycle only
Laparotomy, Drainage of Hypokalemia secondary to 06/15 22.69 17.25 91.14H 26.81L May use IJ Catheter for TPN, IVF, RT an
KCl drip 20meqs + 80cc PNSS to
Intraabdominal Abscess, GI losses 06/15 132.04 L 3.39 L 101.04 0.72 0.50 IV meds
run for 4 hours x 3 cycles –
Adhesiolysis, Primary Repair (-) weakness given 101.32 Please handle aseptically at all times
06/14
of Rectal Injury, Loop (-) tremors H Refer
Ileostomy, JP drain (-) numbness 06/13 134.58 L 3.10 L 101.31
Placement (06/17/2024) Motor 5/5 on all extremities 06/09 138.88 IM Nephro (06/15)
None for now 06/09 If anticipating prolonged NPO, suggest
ORS 1 sachet volume per 06/08 139.27 referral to NST
volume loss Vol per vol 06/05 247.46 5.07 23.08 19.34 IVF: D5LR 1L x 80cc/hour
replacement for vomiting/LBM Diagnostics: Repeat BUN, Crea, Na, K,
06/04 133.30 L 3.86 93.84 H 4.09
– HOLD Mg tomorrow (6/16)
Coagulation studies
Meds: Incorporate 40mEq KCl in curren
Date PT % Activity INR APTT
IVF to run for 1 cycle only
Partial Gut Obstruction 06/15 11.8 102.4 1.05 38.0
secondary to 06/05 11.2 107.7 0.99 37.5 IM NST 06/15
Intraabdominal Abscess Pregnancy Test (06/04/24): NEGATIVE Inquired pharmacy current available
secondary to Grade 2 COVID 19 RAT (06/04/24): NEGATIVE TPN is MG-TNA Pen (Vizcaya) 1400kcal
Rectal Injury 12L ECG (06/04/24): sinus bradycardia in 1920ml
(-) recurrence of vomiting Cefuroxime 500mg/tab, 1 tab Tumor Markers (06/05/2024): Since patient has been on NPO for 4
every 12 hours for 7 days Ca-125: 15.43 days intend to start patient on TCR
Last vomiting: 6/15 8AM Metronidazole 500mg TIV Ca-19-9: 9.92 1000kcal/ day (SF 20x50kg)
yellowish vomitus 1 cup, every 8 hours (D3+2) Papsmear (06/06): MILD TO MODERATE INFLAMMATION CONSISTENT WIH ACUTE CERVICOVAGINITIS Suggesting referral to Surgery service
Cefoxitin 1g TIV every 8 hours Vaginal Discharge KOH 06/04/24) NEGATIVE for TPN access creation
Last BM episode: (D2+1) Vaginal Discharge SGS (06/04/24) SMEAR SHOWS OCCASIONAL GRAM POSITIVE LACTOBACILLI WITH OCCASIONAL LEUKOCYTES AND EPITHELIAL CELLS Once with access initiate TPN: TCR of
6/15 5am yellowish watery Ferrous sulfate 325mg/tab,1 Fecalysis (06/13): Dark mucoid, WBC 10-12, RBC 5-7, NO INTESTINAL PARASITE SEEN 1000kcal/day (SF 20x50 kg using MGtN
stool tab twice a day Intraabdominal abscess GS (06/17): MODERATE GRAM NEGATIVE BACILLI, FEW GRAM POSITIVE COCCI IN SINGLY, PAIRS AND CHAIN MODERATE LEUKOCYTES AND MODERATE Peri 1400kcal in 1920ml to run at
Celecoxib 200 mg/tab 1 tab as EPITHELIAL CELLS WITH PRESENCE OF FUNGAL ELEMENTS. 57ml/hr for 24 hours with the ff
Gyne Wise needed for pain Imaging incorporations:
(-) Severe hypogastric pain Metoclopramide 10mg TIV Abdominal x-ray initial (06/16) Unchanged caliber of bowel 1 amp Vit K, 1 amp MV, 1 vial trace
(-) Profuse vaginal bleeding every 8 hours round the clock Pneumoperitoneum elements, 40meqs of KCL
(+) Flatus Paracetamol 1 TIV q8h RTC Dx:
(+) BM Omeprazole 40mg TIV OD, 30 Chest x-ray initial (06/16) Consider pleural effusion, right [ ] ALB
mins before breakfast [ ] BUN. Crea, Na, K, Phos, Mg, Tca, Cl,
lipid profile, AST, ALT on 06/17, mornin
Abdominal x-ray (06/15) Previous study done June 14, 2024 was reviewed.
Contrast-enhanced CT of the abdomen done the day prior was also noted. Partial Gut Obstruction secondary to
Intraabdominal Abscess secondary to
Free air is still present in the bilateral subdiaphragmatic and anterolateral peritoneal recesses. Grade 2 Rectal Injury
Dilated small bowel segments with air-fluid levels are seen in the center of the abdomen. The rest of the previously noted gas distended Surgery Notes (06/17)
small bowel segments are less delineable in the present study, likely due to identified fluid distension in CT done the day prior. S/P Emergency Exploratory Laparotom
Retained contrast is still appreciated in the urinary bladder, left proximal ureter and bilateral pelvocalyceal systems, exhibiting severe Drainage of Intraabdominal abscess,
dilatation in the right. Adhesiolysis, Primary Repair of rectal
Visualized osseous structures are intact. injury, Loop Ileostomy, JP drain
Impression: placement
Persistent moderate pneumoperitoneum May remove NGT and start on clear
Retained contrast in the urinary system with severe right pelvocaliectasia, as detailed. Suggest correlation with CT. liquids c SAP
Segmental ileus. Cannot rule out beginning small bowel obstruction. Suggest close interval follow up. IVF: Sterofundin ILx100cc/hr
WAB CT Scan with IVC (06/14) Findings: For repeat CBC c PC NA K BUN Crea
initial There are gas and fluid dilated small intestinal segments with the widest transverse diameter of 4.6 cm. There is transition from dilated For abscess GSICS
to collapsed bowel in the region of the right lower abdomen apparently involving the distal ileum. The large bowels are also non- Continue antibiotics
dilated. Provide adequate analgesia
Impression: Monitor ileostomy output q shift and
- Finding of mural discontinuity along the vaginal cuff suture line. Cannot exclude vaginal cuff dehiscence. record
- Dilated small bowel loops with apparent transition point in the distal ileum. Monitor JP drain output q shift and
- Rule-out beginning mechanical distal small bowel obstruction. Suggest follow-up. record
- Moderate pneumoperitoneum, minimal ascites, scattered peritoneal stranding, infraumbilical soft tissue emphysema and Maintain IFC, monitor UO Q1 refer to
abdominopelvic subcutaneous fat stranding, likely part of post SROD if UO<23cc/hr
- Total Abdominal Hysterectomy and Bilateral Salpingoophorectomy changes Monitor VS Q1
- Small-sized right kidney with severe pelvocalyceal dilatation and probable incomplete ureteral duplication Encourage early ambulation & deep
- Incidental chest findings as detailed. breathing exercises
Abdominal x-ray (06/14) Gas-filled small bowel segments are noted. Daily wound & Ileostomy care
Non-differential air-fluid levels are seen. Dr Lutanco updated
Rectal gas is evident.
Free air is seen underneath the right hemidiaphragm. TCVS Notes (06/17)
No abnormal intra-abdominal calcifications visualized. S/P Ultrasound guided IJ catheter
Soft tissues appear unremarkable. insertion. right
Visualized osseous structures are intact. may use IJ catheter as IV access for
Impression: TPN,IVF, BT and for IV meds
Ileus suggest close interval follow up Handle catheter aseptically at all times
Pneumoperitoneum For Post op CXR for Localization
Xray – CHEST/ABDOMEN Chest: Respectfully Signing out TCVS-wise
(6/04/24) There are no active parenchymal opacities in both lungs.
Pulmonary vascular markings are within normal limits. Gastro/NST (06/15/2024)
The heart is not enlarged. Patient seen and examined
Both hemidiaphragms and costophrenic angles are intact. Noted current duration of NPO and
Bony thorax is unremarkable. lastest WAB CT scan
Impression: For referral to respective service
No significant chest findings consultants
Follow-up study (6-4-2024 0655H) shows no significant change since the prior study. Notes to follow
-------------------- Possible initiation of TPN once referred
Abdomen: to NST consultant
The bowel gas pattern is within normal limits. ----
No differential air fluid levels noted. Noted plans for Exlap
Rectal gas is seen. Considering post-op adhesions as cause
There are no abnormal intra-abdominal calcifications. of PGO
The soft tissues do not appear unusual.
The visualized bones are intact.
Impression: Gyne Wise
No localizing signs in the abdomen Wear abdominal binder at all times
PLAIN WHOLE ABDOMINAL CT FINDINGS: Encouraged ambulation
SCAN The liver is normal in size and attenuation with no definite mass noted. Intrahepatic ducts are not dilated. Advised daily wound cleaning
CLINICAL DATA: Gallbladder shows no evidence of hyperdense structures intraluminally. The wall is not thickened.
(+) RLQ PAIN, VOMITING) The pancreas, spleen and adrenals are unremarkable.
(06/03/24) The right kidney is small in size measuring 6.6 x 3.0 cm while the left kidney is normal in size measuring 9.3 x 5.13 cm. No MRA notes (06/15)
hydronephrosis, lithiasis or mass seen. Visualized ureters are not dilated. Clinical Predictor: Intermediate Risk
The small and large bowel loops are in a non-obstructive pattern. No evidence of bowel wall thickening noted. Fecal materials are seen (Renal Insufficiency)
within the colon. The appendix is distinct and measures 0.5 cm. No evident periappendiceal strandings noted. Functional PredictorL Intermediate Risk
No enlarged retroperitoneal nodes seen. Surgical Risk: Intermediate Risk
The urinary bladder is distensible with no stones nor mass. The wall is not thickened. (Exploratory Laparotomy, intra-op)
The uterus measures 6.2 x 5.4 x 5.1 cm, is anteverted and Is unremarkable. Both adnexae show no abnormal findings. Intermediate Risk ( TPN Access creation
There is no evidence of ascites. Overall Medical RiskL Patient has
Minimal spur formation is seen along the anterolateral endplates of the lumbar spine. intermediate risk to develop CP
Visualized lower lungs are unremarkable. complications while on OR
No other findings of note.
IMPRESSION:
CONSIDER RENAL ATROPHY, RIGHT.
NONDILATED APPENDIX WITH NO CT SIGNS OF INFLAMMATION.
MILD/BEGINNING HYPERTROPHIC DEGENERATIVE CHANGES, LUMBAR SPINE.
Surgery Intraoperative findings – Emergency Exploratory Laparotomy (06/17)

Upon opening, drained ~200cc of purulent, foul-smelling fluid collection at the pelvis and right hemiabdomen. The small bowels were slightly dilated. On bowel run, noted interloop
abscesses in the small bowel segments. Noted soft adhesions with pockets of abscesses at 50cm, 60cm, and 100cm from ileocecal valve with transition point identified 20cm from the
ileocecal valve. The large bowel was not dilated and appear grossly normal. On pelvic washing and exploration, identified a 1.5cm full thickness perforation at the anterior portion of the
upper rectum, adjacent to the vaginal stump, with noted spillage of foul-smelling fecaloid fluid. Injury confirmed with digital rectal examination and internal examination. Primary repair
of injury done. Loop ileostomy created and matured at the right upper quadrant. No active bleeding prior to closure.
EBL: 60cc
Surgery Intraoperative findings – Ultrasound-guided IJ catheter insertion, Right (06/17)

IJ vein interrogated, no noted filling defects.
Noted good inflow and outflow of venous blood from both ports. Guidewire removed and inspected
EBL: minimal
Intraoperative findings:
On laparotomy:
No noted ascites.
The uterus approximately measures 5 x 5 x 3.5 cm. Multiple myoma noted at the uterus as follows:
M1: anterior fundal measuring 2.5 x 1 x 0.8cm
M2: fundal subserous measuring 6 x 4.5 x 4cm
M3: left posterior intramural measuring 3 x 3 x 2cm
The right ovary is cystically enlarged measuring 11 x 9.5 x 5.3 cm, twisted once around its pedicle while the left ovary is normal in size measuring 2 x 1 x 1 cm.
Both fallopian tubes are normal, the right fallopian tube measures 6 x 1 x 0.5 cm
while the left fallopian tube measures 8 x 2 x 1.5 cm
On cut section of right ovary, the cyst is noted to be unilocular and drained serous fluid.
Stool charting
06/15 8 episodes of loose stools
Gyne 2 G2P2 (2002) BPR 90-100/60-70 Diet: 1350 (SF 30) with PF 1.5 CBC with PC
HILARIO, AILEEN MENDOZA Pelvoabdominal mass BP 90/60 Using regular diet divided into Date Hgb Hct WBC S L M E Plt
44 probably uterine in origin, HR 89 3 meals and 2 snacks with the ff 06/08 s/p
NYC probably malignant RR 20 (1.5) CHON 68 g 270 kcal 9.9 L 0.30 L 12.3 76 10 12 2 465
BT of 4u
Hypovolemic shock T 36.8 CHO 160 650
06/08 8.4 L 0.26 L 13.5 H 82 7 10 1 460
05/29/2024 (resolved) secondary from CHO 160 650
3931666 severe anemia probably I: 1300 Fats 50 430 05/30
S/p BT of 11.1 0.34 22.7 H 86 7 6 1 393
Dr Calo/ Tungcul/Gavino(TL)/ secondary to chronic blood O: 800 Boost optimum 2 scoops
3u pRBC
De Guia Gauiran/ loss beneprotein 2 times a day as
Kadappurath Tiongson Blood transfusion of 4 units Ht: 157cm snacks – HOLD (06/05) 05/30
pRBC for anemia very severe Wt: 45kg Heplock s/p BT of 9.1 L 0.30 L 20.7 H 84 9 6 1 400
prob secondary to 1) Chronic BMI: 18.3 (underweight) 2u pRBC
blood loss 2) Chronic disease 05/29 5.2L 0.19L 18.9H 80 12 7 1 544H Hypovolemic shock (resolved)
(malignancy) 3) Nutritional s/p BT of 4units pRBC O+/NR secondary from severe anemia
Transaminitis from Ischemic Carvedilol 6.25mg/tab,1 tab 2x Urinalysis probably secondary to
Hepatopathy Hypovolemic shock a day Date Sugar Protein WBC RBC Epithelial Bacteria 1) Chronic blood loss
Non-alcoholic fatty liver (resolved) secondary from Diphehydramine 50mg IV 30 2) Chronic disease (malignancy)
Infectious Diarrhea, resolved severe anemia probably minutes prior to BT-given 06/01 Neg Trace 1-2 51-75 H Few Few 3) Nutritional
Complicated UTI, corrected secondary to Paracetamol 300mg IV 30 s/p BT of 4units pRBC
05/29 Neg Neg 15-20 H 0-2 Few Few
Hypoalbuminemia 1) Chronic blood loss minutes prior to BT-given
Multiple electrolyte 2) Chronic disease Calcium gluconate 10% 10cc Chemistry:
imbalance (Hypovolemic, (malignancy) SIVP post BT of 3u PRBC – given Na K AST ALT Cl iCa Mg Phos Trop I Albumi Total Bil Ibil Dbil IM Hema 06/04
Date BUN Crea
Hypoosmolar, Hyponatremia 3) Nutritional, STANDBY Norepinephrine n Elevated platelet count can be
and hypokalemia) secondary (-) hypotension 16mg + D5W 500mL to run at 06/1 13.65 7.64 6.01 attributed to possible malignancy
to poor oral intake, (-) loss of consciousness 18cc/hr(0.2mcg/kg/min) to 4 Monitor CBC for now, no hema referra
corrected (-) DOB/SOB regulate at increments of +/- 06/1 69.98 H 29.45 H warranted
Underweight (-) tachycardia 3cc/hr every 15 minutes to 2
(-) slight pallor maintain BP =90/60mmHg 06/1 33.57 L
(-) generalized body (max: 54 ugtts/min) 0
weakness 06/0 134.86 L 3.84
(-) dizziness 9 Transaminitis from Ischemic
pink palpebral conjunctiva 06/0 133.19 L 3.48 68.56 H 29.81 Hepatopathy; Non-alcoholic fatty live
Last hypotension: 05/29: 8 L
70/40  Norepinephrine 06/0 134.78 L 4.00 97.42 0.83 1.08 25.72 L GASTRO NOTES (06/13)
110/70 7 Please facilitate administration of
06/0 133.52 L 4.56 1.15 0.82 0.86 Ciprofloxacin
Transaminitis from Essential Phospholipid caps, 2 2.00 22.51 Continue Ciprofloxacin 500 mg/tab
5
Ischemic Hepatopathy; caps 3x/day 06/0 132.41 L 24.84 L every 12 hours to complete 7 days
Non-alcoholic fatty liver Aminoleban sachet, 1 sachet 3x 5 Continue Essential Phospholipids,
(-)change in sensorium a day Aminoleban
06/0 129.47 L 3.56 105.61 H 28.78 0.78 1.39
(-) jaundice Carvedilol 6.25mg/tab,1 tab 2x 2.16 28.36 L Increase Carvedilol to 12.5 mg/tab 2x a
4
(+) intermittent abdominal a day day
06/0 129.51 L 4.9 94.91 0.81 1.79 26.34 L
pain 2.08 L 28.24 L
3 L H
(-) chest pain Surgery 06/15/2024
06/0 134.74 4.90 0.75 0.96
(-) DOB/SOB No objections for discharge
2
(-) vomiting Ciprofloxacin 500mg tab 1 tab Still suggesting image guided UTZ of
every 12 hours to complete 7 06/0 3.40 130.04 H 34.92 H pelvoabdominal mass
Infectious diarrhea, days – completed 06/14 1 L Refer back as OPD basis once with
resolved Racecadotril 100mg/tab 1 tab 05/3 136.44 3.14 0.75 0.63 L biopsy result
2.12 L 28.85 L
(+) loose stools every 8 hours until 2 formed 1 L Respectfully signing out of this case
(-) tenderness on stools 05/3 138.21 3.73 0.77 17.16 L
hypogastric area Probiotics sachet 1 sachet once 0
(-) weakness a day 05/2 130.25L 3.19L 16.66 L Infectious diarrhea, resolved
Oresol volume per volume 9 Stool charting
06/17 2100H replacement 05/2 125.02 L 2.68 120.91 H 36.72 H 94.57 1.01 0.83 0.96 0.31
1.84 34.43
2 episodes of watery stools HNBB 10mg TIV every 8 hours 9 L L IM notes (06/13)
Coagulation studies Noted plans for discharge, no objection
Hypoalbuminemia Human Albumin 20% vial/ vial Date PT % Activity INR APTT for possible discharge
(-) edema every 12 hours for 3 days 05/08 13.3 91.0 1.19 33.8 THM:
(-) fatigue (completed 06/10 0800H) 05/30 15.2 H 75.6 1.37 H 39.4 1. Ciprofloxacin 500 mg/tab, 1 tablet
(-) DOB 05/30 17.0 66.2 1.55 39.0 twice a day to complete 7 days
(-) loss of appetite 05/29 18.2 61.6 H 1.67 37.1 2. Essential phospholipids 2 caps 3x a
Tumor markers day
Multiple electrolyte Glutaphos tab 1 tab 3x/day Date CA 125 CA 19-9 CEA 3. Carvedilol 12.5 mg/tab, 1 tablet twic
imbalance (Hypovolemic, KCl 750mg/tab 2 tabs PO every a day
06/15 1.82
Hypoosmolar, 4 hours x 2doses only – given Advised for strict medication
05/30 32.22 13.41
Hyponatremia and compliance
Hepatitis Profile (06/14/24)
hypokalemia) secondary to HbsAg NR
poor oral intake, corrected Anti-HAV R Hypoalbuminemia
(-) chest pain Anti-HAV IgM NR Gastro Notes (06/07/24)
(-) DOB/SOB Anti-HCV NR For Human Albumin 20% vial/ vial ever
(-) dyspnea Anti-HBc IgG R 12 hours for 3 days
(-) anorexia Anti-HBc IgM NR
(-) diarrhea Multiple electrolyte imbalance
HbeAg NR
(Hypovolemic, Hypoosmolar,
AntiHBS NR
Cranial nerves Hyponatremia and hypokalemia)
AntiHBe NR
II, III: (+) 3mm EBRTL secondary to poor oral intake,
III, IV, VI: (+) EOMs, primary Reticulocyte count (05/29 OSMAK): 5.2H corrected
gaze midline PBS (05/30/24)
V: V1-V3 intact Platelet: SLIGHTLY INCREASED IM-Nephro notes (06/10)
VII: No facial asymmetry RBC: MODERATE MICROCYTOSIS,HYPOCHROMIA WITH ANISOCYTOSIS AND POIKILOCYTOSIS ( TARGET CELLS,BURR CELLS,FEW SPHEROCYTES). Diet c/o NST
VIII: (+) gross hearing WBC: NO ABNORMAL CELLS SEEN Noted repeat labs
IX, X: Can swallow CRP (05/29 OSMAK): >10.00 H Since within normal results of Na, K,
XI: Good shoulder shrug Ferritin (05/29 OSMAK): 43.97 respectfully signing out, refer back if
XII: tongue midline 12L ECG (05/29 OSMAK): NSR warranted
Fecal occult blood (05/29 OSMAK): Negative
Motor BEDSIDE PT (5/29/24): NEGATIVE NST Notes (06/02)
RUE 5/5 LUE 5/5 Fecalysis Revise diet to 1350 (SF 30) with PF 1.5
RLE 5/5 LLE 5/5 Date WBC RBC Other Using regular diet divided into 3 meals
NO INTESTINAL watery and 2 snacks with the ff
06/09 40-50 5-10
Sensory PARASITE SEEN (1.5) CHON 68 g 270 kcal
RUE 100% LUE 100% NO INTESTINAL CHO 160 650
06/04 >100 10-15 watery
RLE 100% LLE 100% Ceftriaxone 2g TIV once a day PARASITE SEEN CHO 160 650
(completed) Imaging Fats 50 430
Complicated UTI, resolved FINDINGS: Continue ORS with beneprotein
(-) dysuria A non-calcified interfissural nodule is noted along the left oblique fissure measuring 0.2 cm. Start 24 hour food recall c/o dietary
(-) fever Reticulonodular densities are again seen in the lateral basal segment of the right lower lobe, better seen in the post-
(-) chills contrast images. Linear densities are appreciated in the anterior segment of the right upper lobe, middle lobe segments
(-) increased urine and lateral basal segment of the right lower lobe. Complicated UTI, resolved
frequency No meds for now Mediastinal structures are in place. The heart is not enlarged. The aorta and great vessels are For antibiotic completion
normal in course and caliber. Minimal segmental wall calcifications are seen along the aorta and some its coronary
Gyne wise branches. IM-IDS notes (06/04)
No profuse vaginal bleeding Trachea and mainstem bronchi are patent with no endobronchial lesion. Negative for pleural or Continue Ceftriaxone 2g TIV OD until
No severe hypogastric pain pericardial effusion. Day 7, IDS respectfully signing out
No enlarged hilar or mediastinal lymph nodes
G2P2 (2002) Osteophytes are seen along the margins of the visualized spine. Sclerotic focus is seen in the Tg Gyne wise
LMP: Last week of March vertebral body, may represent bone island. Still for discharge – For Birthday
2024 CECT of chest OSMAK initial (6/14/24) initial No abnormal enhancement noted after contrast infusion. correction on PhilHealth (Tentative dat
PMP: Unrecalled There is diffuse decrease in parenchymal attenuation of the liver in relation to the spleen. The main portal vein remains of discharge 06/18/2024 since holiday
PMP: Unrecalled dilated measuring 1.6 cm in its maximal diameter. The visualized spleen appears enlarged. Other abdominal structures on Monday)
appear unremarkable. For surgical planning as OPD basis
soft flabby abdomen, Impression: For bone scan as OPD basis
palpable hypogastric mass No CT evidence of enhancing pulmonary mass or nodule Daily body and perineal hygiene
from below the umbilicus to Non-calcified interfissural nodule. Suggest followup Monitor vs q4
hypogastric area, 13x9cm Reticulonodular densities, right lower lobe, may represent an infectious or inflammatory process. Strict I and O
size, nonmovable with Subsegmental atelectasis versus fibrosis, right lung WOF: severe abdominal pain, nausea
direct tenderness on Mild atherosclerotic vessel disease and vomiting, DOB/SOB, chest pain,
palpation Degenerative osseous changes weakness
Hepatic steatosis
SE: Cervix flushed to the Unchanged dilatation of the main portal vein. Please correlate with pertinent parameters Gyne Onco (06/13)
vault, no mass, no erosions, Splenomegaly Rounds with Dr. Alfabeto
no bleeding per os CECT of the Abdomen CLINICAL DATA: 5-month history of gradually enlarging pelvoabdominal mass with unintentional weight loss For hepatitis profile, total Bili, Indirect
OSMAK COMPARISON: None Bili, Direct bili – done
IE: cervix flushed to the 06/07/24 TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained with oral, rectal and intravenous contrast. For bone scan and chest CT scan with
vault, closed, uterus cannot FINDINGS: IVC
be palpated due to A 11.1 x 14.3 x 13.7 cm (ApxWxCC) lobulated, heterogeneously enhancing mass with areas of necrosis and internal air For home once imaging done and
enlarged mass pockets arising from the pelvic region extending into the peritoneal cavity. It is compresses on the urinary bladder, infectious diarrhea resolved
intimately related to its superoposterior wall with no distinct fat planes. It severely compresses on the rectosigmoid and For OR scheduling: EL, EHBSO tumor
descending colon but maintains fair planes of differentiation. It is also seen mildly compressing some of the small bowels debunking
(jejunum) and left common iliac vein, also maintaining good planes of differentiation. The uterus and ovaries are not Once with OR plans, for referral to
clearly delineated. Minimal fluid collection is seen in the pelvic space. urology for possible cystectomy and GS
for possible Hartmanns procedure
The liver is enlarged with a span of 16.3 cm. Diffuse decrease of parenchymal attenuation with smooth borders is noted.
Intrahepatic ducts are not dilated. The main portal vein is patent but dilated with a maximum diameter of 1.6 cm. No IM Pulmo (05/29)
abnormal enhancement after contrast infusion. Referred to Dr. Arguila
Cleared for regular ward
The spleen is enlarged measuring 4.6 x 11.9 x 10.1 cm with an index of 553. The splenic veins are dilated. No distinct mass Respectfully signing out
or abnormal parenchymal enhancement observed.
The normal-sized gallbladder exhibits no abnormal intraluminal densities. Wall is not thickened. Common duct is not SURGERY Notes (06/14)
dilated. Dr. Gomez updated
The pancreas is normal in size and configuration. Pancreatic duct is not dilated. No objections for discharge
The adrenal glands are normal without undue enhancement. Still suggesting image-guided biopsy of
Both kidneys are normal in size and exhibit symmetrical parenchymal enhancement. A few non-enhancing hypodense abdominal mass
foci are seen in the left kidney with the largest measuring 1.7 x 1.5 x 1.6 cm located in its interpolar region. A non- Refer back as OPD basis once with
enhancing hyperdense focus is likewise seen in the superior pole of the left kidney measuring 1.2 x 1.2 x 1.1 cm. No biopsy results
evidence of opaque lithiasis or hydronephrosis.
The appendix is not dilated. The included esophagus, stomach and intestinal segments are grossly normal. Urology (06/13)
Prominent and enlarged lymph nodes are seen in the left paraaortic, mesenteric, and right iliac chains, with the largest No immediate surgical intervention uro
detected in the right iliac chain measuring 1.8 cm along its short-axis diameter. wise
Minimal osteophytes are seen along the margins of the visualized spine. Sclerotic foci are seen in the T9 and L5 vertebral Will await gyne-onco plans
bodies. The lumbar lordosis is straightened. If for OR for placement of bilateral
Diffuse subcutaneous stranding densities are noted. stent*
Reticulonodular densities are seen in both visualized lower lobes.
Impression: Pending Labs
- Large and enhancing pelvoabdominal mass with areas of necrosis, extension and mass effects, as detailed. Neoplasm is [x] Urine CS – not amenable
the primary consideration. Tissue correlation is advised With refusal form
- Hepatosplenomegaly with signs of portal hypertension. Please correlate with pertinent parameters [x] Blood CS x 2 sites – not amenable
- Peritoneal and pelvic lymphadenopathies With refusal form
- Minimal pelvic ascites [x] repeat ABG not amenable
- Left renal cysts (Bosniak I and II) With refusal form
- Diffuse subcutaneous edema
- Degenerative osseous changes *Patient and relative amenable for
- Sclerotic foci, T9 and L5 vertebral bodies, may represent bone islands, however, metastatic process is not entirely ruled surgical procedure
out if with proven malignancy. Follow-up is suggested
- Straightened lumbar lordosis likely due to muscle strain Advance directives (05/29/24):
- Reticulonodular densities, both lower lobes. Consider an inflammatory/infectious process. Please correlate clinically Yes to all
UTERUS: 20.72x12.18x10.98cm
TVS shows an enlarged uterus, heterogenous, with irregular solid components, with moderate color on color flow
mapping
ENDOMETRIUM not delineated
CERVIX: 3.38x2.78cm
TVS UTZ c/o OB sono (05/31/24 OSMAK)
RO: not seen
LO: not seen
Impression:
Pelovoabdominal mass probably uterine in origin, t/c a non-benign pathology
Endometrium and bilateral ovaries not visualized
Both kidneys are normal in size with smooth and regular contour. The cortico-medullary pattern in both sides is intact.
The right kidney measures 10.2 x 5.1 x 3.7 cm with cortical thickness of 1.0 cm. The left kidney measures 10.3 x 5.3 x 4.2
cm with cortical thickness of 0.9 cm. There is no evidence of hydronephrosis, lithiasis or mass noted in both kidneys. The
KUB UTZ urinary bladder is adequately distended. Its wall appears to be thickened measuring 0.7 cm. An indwelling foley catheter
OSMAK balloon is seen within.There is incidental note of increased hepatic parenchymal echogenicity with minimal fluid in the
(5/30/24) perihepatic space.
Impression:
Minimal perihepatic ascites. Incidental note of hepatic steatosis. Unremarkable ultrasound of both kidneys. Nonspecific
urinary bladder wall thickening. Correlate clinically.
Focused scanning of the hypogastric/pelvic region shows an ill-defined, heterogeneous mass with internal calcifications
and with moderate vascularity upon Doppler interrogation, measuring approximately 11.4 x 12.6 x 10 cm. It has apparent
extension into the superoposterior portion of the urinary bladder. The right ovary is normal in size measuring 2.8 x 2 x 2.6
Focused ultrasound of hypogastric /pelvic
cm (volume of 7.6 cc). No focal lesions seen. The left ovary is not visualized.
region (05/29/24 OSMAK)
IMPRESSION:
Pelvoabdominal mass with possible urinary bladder extension. Pelvic MRI is recommended for further evaluation.
Normal sonogram of the right ovary. Non-visualized left ovary
Chest / Abdomen xray (05/29/24 OSMAK) Chest:
An ovoid opacity is noted in the left upper lung. Pulmonary vascular markings are within normal limits. The heart is not
enlarged. Both hemidiaphragms and costophrenic angles are intact. Bony thorax is unremarkable.
Impression:
Consider pulmonary granuloma, left upper lung
Abdomen:
The bowel gas pattern is within normal limits. Considerable amount of fecal material is noted in the colon.
There are no abnormal intra-abdominal calcifications. The soft tissues do not appear unusual.
The visualized bones are intact.
Impression:
Fecal retention
Stool charting
06/13 discontinued
06/12 1 soft stool
06/11 2 loose stools
06/09 3 watery stools
Gyne 5 G1P1 (1001) BPR 110-130/70-80 NPO CBC with PC
LANOSGA, CRISTINA Multiple Myoma uteri BP 130/80 IVF: D5LR 1L x 30 gtts/min Date Hgb Hct WBC S L M E Plt *2 u pRBC crossmatched c/o Maam
BUGARIN Menopause for 12 years HR 78 Micah
06/16 12.7 0.38 8.1 69 21 7 198
67 RR 20 *amenable for send out of specimen at
YC Chronic Venous Insufficiency T 36.6 B+/NR ACE Pateros
HASCVD, CAD, HfpEF (51%), Coagulation Test
219407 NYHA II I: 1000 (16 hr) Date PT % Activity INR APTT
06/16/24 0: 900 (16 hr) 06/16 11.5 105.0 1.02 36.0
Dr. Calo/ Tungcul/ Go(TL)/ Hypertension St II, Urinalysis
Gavino/ Gauiran/ Gallano/ controlled Wt: 75.3kg Date Sugar Protein WBC RBC Epithelial Bacteria
Tiongson, Alzaga Ht: 161 cm 06/16 NEG NEG 1.0 0.8 12.8 9835.8 H
Type 2 Diabetes Mellitus, BMI: 29 (Overweight) Chemistry
Controlled Date BUN Crea BUA Na K Cl AST ALT
06/16 5.38 79.21 311.75 141.21 4.22 106.87 17.03 7.69
Cholecystolithiasis Hba1c (06/16/24) 5.78%
Sulodexide 250mg/cap 1 cap ECG (6/16/24): NSR Chronic Venous Insufficiency
Chronic Venous
Urinary Tract Infection OD HASCVD, CAD, HfpEF (51%), NYHA II
Insufficiency Imaging:
Diosmin + Hesperidine Continue other medications as advised
HASCVD, CAD, HfpEF (51%), Transvaginal ultrasound Clinical data: Right lower quadrant mass
500mg/cap 2 caps OD by MRA prior to admission
NYHA II May 3, 2024 LMP: Menopause
(-) body weakness
OSMAK IM Notes (06/17)
(-) chest pain Findings Continue Sulodexide 250mg/cap 1 cap
(-) chest heaviness Uterus is anteverted and enlarged measuring 16.0 x 8.2 x 8.0 cm OD
Myometrial echopattern is heterogeneous. Diosmin + Hesperidine 500mg/cap 2
There are multiple varisized ovoid foci with the following characteristics, measurements and location: caps OD
1. Anterofundal wall measuring 4.2 x 4.3 x 5.0 cm.
2. Posterofundal wall measuring 5.4 x 4.7 x 5.0 cm. Intralesional calcifications are seen. Vascular Notes (06/16/24)
Losartan 100mg/tab OD 3. Anterior lower uterine wall measuring 2.8 x 3.4 x 3.2 cm, with intralesional calcifications Continue Sulodxide 250mg tab OD
Hypertension St II, 4. Anterior lower uterine wall measuring 5.1 x 5.4 x 5.1 cm.
Trimetazidine 35mg Twice Daily Diosmin + Hisperidine 500mg tab 2 cap
controlled 5. Posterior lower uterine wall measuring 5.5 x 5.8 x 5.7 cm.
Atorvastatin 40 mg/tab 1 tab OD
(-) headache Endometrial lining cannot be clearly delineated.
OD
(-) dizziness Both ovaries are not visualized. Hypertension St II, controlled
(-) chest pain No definite evidence of fluid seen in the posterior cul-de-sac. For BP monitoring and control
(-) DOB/ SOB IMPRESSION:
(-) vomiting Enlarged anteverted uterus with multiple myoma as described. IM Notes (06/17)
Non- visualized ovaries. Continue Atorvastatin 40 mg/tab 1 tab
No fluid in the posterior cul-de-sac. OD
Type 2 Diabetes Mellitus, Chest Xray initial No acute opacities
Controlled
Metformin 500mg OD – HOLD (6/16/24):
(-) polyphagia
on day of admission
(-) polydipsia
Insulin sliding scale as follows:
(-) polyuria
180-120- 4 units
See CBG table
220- 260- 6u Type 2 Diabetes Mellitus, Controlled
260-300- 8u Hold Metformin upon admission as per
>300 10 units MRA
Atorvastatin 40 mg tab 1 tab For CBG monitoring every 6 hours once
once a day on NPO
IM Notes (06/17/24)
Cholecystolithiasis
Continue Insulin sliding scale
(-) fever
Ursodeoxycholic Acid
(-) jaundice
300mg/capsule, 1 cap TID Cholecystolithiasis
(-) abdominal pain
Urinary Tract Infection
(-) dysuria
(-) hematuria Ceftriaxone 2gm TIV OD () ANST
(-) fever x 3 days Urinary Tract Infection
For completion of antibiotics
Gyne wise For repeat UA on Day 3 of antibiotic
No profuse vaginal bleeding (June 19)
No severe hypogastric pain
Cefoxitin 2g TIV LD ( )- ANST 30 IM Notes (06/17)
G1P1(1001) mins prior to OR- HOLD Continue Ceftriaxone 2g TIV OD
Menopause for 12 years Metronidazole 1g IV 30 mins For urine CS
prior to OR
GYNE PE(4/25/24) Bisacodyl 2 suppositories per
Flabby soft nontender rectum at 0500H, June 18
abdomen Fleet enema on June 18 at Gyne wise
(+) palpable firm 10x10cm, 0900H For total abdominal hysterectomy with
non-moveable, nontender Omeprazole 40mg TIV OD while bilateral salpingooophorectomy on Jun
mass occupying right lower on NPO 18, Tuesday, (1300H)
quadrant, Informed AROD (Dr.Dalmacion)
SE: cervix pinkish, no Monitor VS q4 and record
lesions, no mass, no I & O qshift and record
bleeding per os
IE: cervix closed, no CMT, MRA Notes (06/16/24)
uterus enlarged to 20 Referred back to Dr. Diaz- Garcia
weeks size, no AMT MRA clearance for TAHBSO
Clinical – intermediate
Functional – intermediate
Surgical – intermediate
Overall – intermediate risk for cardio
pulmonary complications
Anes Notes (06/17)

Secure 2u pRBC properly typed and
crossmatched
CBG and VS prior to wheel in please
inform AROD at loc 1416
Gyne 6 Nulligravid BP 100/60 NPO CBC with PC

TANDOY, RIE MEI QUIJANO Pelvoabdominal mass HR 69 IVF: D5LR 1L x 30gtts/min Date Hgb Hct WBC S L M E Plt *2 u pRBC crossmatched c/o Maam
25 Ovarian New Growth, right, RR 20 Micah
06/13 12.5 0.37 4.5 59 32 7 2 164
YC t/c mucinous tumor with T 36.5
borderline malignant O+/NR
3931040 potential Wt:57.8kg Coagulation Test Frozen section – to be done here at
06/16/24 Ht: 152.5cm Date PT % ACT INR APTT OSMAK
Dr. Odevilas/ Tungcul/Gavino, BMI: 25 overweight) 06/13 12.7 95.5 1.13 39.6 Histopath – to send out to St.Luke’s c
Reyes (TL)/Gallano, Urinalysis Coordinated with St. Luke’s BGC.
Gauiran/Alzaga, Tiongson Date Sugar Protein WBC RBC Epithelial Bacteria
I: 750 06/16 NEG NEG 1.2 0.5 17.7 8.8 Medtech: sir Jerric
O: 700 06/13 NEG NEG 7.1 0.5 106.1 H 500.4 H Senior med tech: sir Ike Reyes
Chemistry Patho ROD: Janney Kho
Date FBS BUN Crea Na K Cl AST ALT Approved by histopath head: Dr. Ann
Gyne wise 5.06 51.47 44.73 Margaret.
No profuse vaginal bleeding Cefoxitin 2g TIV as LD 30 mins 06/13 3.01 61.37 137.08 4.02 103.91
H H
No severe hypogastric pain prior to OR Tumor markers
(+) pelvic heaviness Metronidazole 1g TIV 30 mins Date CA 125 CA 199 Gyne wise
prior to OR 05/22 79.4 24 PLAN: For Oophorocystectomy possible
Nulligravid Bisacodyl 5mg/tab, 2 tabs PO oophorectomy (left) with frozen section
Hba1c (06/13/24) 4.91%
LMP: May 5-9,2024 on June 18, 2024 – 0000H, on June 18, 2024 8 AM
PMP: April 19-25 suppository 2 tabs Pregnancy Test NEGATIVE Monitor VS q4
PMP: March (unrecalled) Fleet enema on June 18, 2024 – Chest Xray (06/12/24): No significant chest findings I and O q shift and record
0500H ECG (06/16/24): Normal Sinus Rhythm For final APEC clearance
Globular abdomen, non- Omeprazole 40mg TIV OD AM Imaging: Inform AROD (Dr Dalmacion)
tender, (-) muscle guarding while NPO Pelvic UTZ (05/17/24) Clinical data: Nulligravid; gradually enlarging pelvoabdominal mass Monitor CBG Q4 hours while on NPO
Abdominal girth: 96cm OSMAK Findings:
(+) large pelvoabominal A multiloculated cystic mass with intramural solid components and floating low-level echoes is seen
mass with superior portion superior to the uterus spanning almost the entire abdomen up to its subxiphoid region, displacing some
4 fingerbreath away from visualized bowel segments. It measures at least 28.4 x 19.3 x 17.5 cm (CcxWxAP) with minimal vascularity Anes Notes (06/17)
the xiphoid process (mass upon Doppler interrogation. Secure 2u pRBC properly typed and
around 27x20cm) crossmatched
The uterus is normal in size measuring 4.2 x 2.8 x 3.7 cm (volume of 22.1 mL). CBG and VS prior to wheel in please
Myometrial echopattern is homogeneous. inform AROD at loc 1416
No focal mass is seen.
Endometrial lining is not thickened measuring 0.2 cm.
The right ovary is slightly enlarged measuring 4.2 x 4.7 x 2.4 cm (volume of 24.7 mL). There is a unilocular
cyst within measuring 3.6 x 3.4 x 2.0 cm (volume 13.2 mL) with no vascularity upon Doppler interrogation.
The left ovary is not visualized.
The cervix is normal in size measuring 1.6 x 1.7 x 1.8 cm. No focal lesions identified.Minimal fluid
collection is seen in the posterior cul-de-sac fluid.
Impression:
Multiloculated pelvoabdominal cystic mass with intramural solid components and floating low-level
echoes. Suggest pelvic MRI for better evaluation.
Normal-sized uterus with non-thickened endometrium
Enlarged right ovary with unilocular cyst (IOTA Simple Rules B1, B5)
Minimal posterior cul-de-sac fluid
Unremarkable sonogram of the cervix
PELVIC UTZ (c/o OB Multiple transabdominal convex B-mode scans of the Pelvis along perpendicular planes
SONO, ST. CLAIRE, show a complex, predominantly cystic, multi-loculate mass that measures 20.5(L) x 13.8(AP) x
5/18/24) 23.1(W) cm and which occupies the right midsection of the abdomen down to the right adnexal
area. The Cyst Capsule measures 8.6 – 12.8 mm thick at its infero-medial aspect in the vicinity where
there is a tendency for the locules to be crowded in groups. The septa in the superior
portion of the mass measure 3.87 mm – 4.23 mm thick (Iota B feature) and appear generally smooth (lota
B-feature). Close scrutiny of the right lower portion of the mass shows “wart-like”
inward protrusions of the capsule that measure 5.57 cm thick (lota M-feature). Color flow scans
of these vascular internal capsular protuberances reveal vascularity of adjacent external hylar vessels. The
protuberances themselves do not show any color flow (Color Score= 1).
The Uterus is anteverted and displaced inferomedially by the previously described right
abdominopelvic mass. The Cervix measures 2.08(L x 2.01(AP) x 2.26(W) cm and appears
homogeneous. The Uterine Corpus measures 4.82(L) x 3.81(AP) x 4.51(W) cm and also appears
homogenous and moderately echogenic. The Endometrial Stripe appears isoechoic to
myometrium and measures 6.10 mm thick. Its midline echo and subendometrial echolucent zone
appear intact.
The Left Ovary measures 3.55(L) x 1.64(AP) x 2.69(W) cm and has moderately
echogenic stroma and a follicle-laiden surface echotexture.
A minimal amount of echolucent free fluid is evident in the posterior cul-de-sac.
Impression:
COMPLEX MASS, RIGHT ADNEXAL AREA, PROBABLY OVARIAN, WITH
BOTH IOTA B AND M FEATURES WHICH CANNOT BE DEFINITELY CLASSIFIED BY
THE IOTA SYSTEM. CONSIDER A MUCINOUS TUMOR OF THE OVARY WITH
BORDERLINE MALIGNANT POTENTIAL, NORMAL SIZE ANTEVERTED UTERUS.
MILDLY THICK ENDOMETRIAL STRIPE. NORMAL SIZE LEFT OVARY. MINIMAL
FREE FLUID, POSTERIOR CUL-DE-SAC.
WAB CT Reproductive organs: 151 x 231 x 302 mm (AP, with and cranio-caudal dimensions) Multi-septated
(5/17/24) abdomino-pelvic cystic mass of varying densities. Faint calcifications noted along some of the septa.
MMC Liver: Unremarkable
Gallbladder and biliary tree: No lithiasis. No intra- or extra-hepatic biliary ductal dilatation.
Pancreas: Unremarkable
Spleen: Unremarkable
Adrenals: Normal.
Kidneys and ureters: Unremarkable
Urinary bladder: Well distended.
Bowel: Normal in caliber.
Lymph nodes: No enlarged lymph nodes,
Peritoneum/Retroperitoneum: Minimal pelvie ascites.
Abdominal wall: Normal
Bones: Normal.
IMPRESSION:
1. Multi-septated, abdomino-pelvic cystic mass of varying densities. Consider a left ovarian complex
cystadenoma.
2. Minimal pelvic ascites.
PERIPHERALS
SARI 3 BED 3 Nulligravid BPR 140-160/70-90 NPO CBC with PC
LIPARDO, MARY GRACE AUB-A,M,O BP 140/70 IVF: Nicardipine drip: Date Hgb Hct WBC S L M E Plt
CASTA Blood Transfusion of 3 units pRBC HR: 70 Nicardipine drip 90mL + 10mg in
38 for Anemia severe secondary to 1) RR: 20 Soluset to run at 5ugtts/min to 06/15 7.6 0.22 13.1 85 7 4 4 258 *IFC refused
NYC malignancy 2) chronic blood loss T: 36.9 regulate at increments 06/12 8.4 L 0.24 L 9.8 83 7 6 4 245 s/p HD – 06/17/24
ESRD sec to HTN NSS vs DKD Type O2: 98% of +/- 2-3ugtts/min every 15 06/10
3890682 2 Diabetes Mellitus, controlled minutes to achieve target BP s/p BT
06/08/2024 Hypertension Stage II, controlled I: 700 <160/100 – HOLD 06/17 7.4 L 0.21 L 10.8 88 6 5 1 268
of 2u
Dr. Odevilas/ Tungcul, Proliferative diabetic retinopathy, O: 4000 (+) cardiac monitor pRBC
Ballesteros, De Paz (TL)/ De both eyes Vitreous hemorrhage, (+) O2 support at 4LPM via nasal
Guia, Pesigan/ Jasarino, left eye Ht 5’2’’ cannula 06/08 4.9 L 0.14 L 8.5 84 10 5 1 343
Vito t/c Hospital Acquired Pneumonia Wt 84kg (+) IFC A+/NR
s/p Panretinal photocoagulation, BMI 33.8 Urinalysis
right eye Date Sugar Protein WBC RBC Epithelial Bacteria
s/p Removal of Permanent Anemia severe secondary to s/p BT of 3 unit pRBC Anemia severe secondary to 1) malignancy 2) chronic blood loss
catheter, Right; Ultrasound- 1) malignancy 2) chronic Diphenhydramine 50mg IV 30 Chemistry: s/p BT of 3 u pRBC
guided IJ catheter insertion, Left blood loss minutes prior to BT – given Date BUN Crea Na K Cl iCa Mg Phos AST ALT Give Furosemide 40mg IV after each aliquot with BP precaution
(06/17/2024) (+) slight pallor Paracetamol 300mg IV 30 06/15 36.01 2042.53H 132.91 4.69 3.17 For repeat CBC 6 hours post BT of 3rd unit pRBC (0800H)
(+) slightly pale palpebral minutes prior to BT – given 06/12 4.25 1.30 1.08 H 2.86 H IM notes (06/16/24)
conjunctiva Calcium gluconate 10% 10cc 06/10 6.45 H Suggest anemia correction
(-) easy fatiguability SIVP post BT of 3u PRBC 06/10 6.78 H For transfusion of 1 unit pRBC divided into 2 aliquot to run for 6
(-) dizziness Furosemide 40mg IV after each hours each aliquot with 2 hours interval
06/08 37.79 H 2,184.72 H 129.33 L 7.17 H 97.04 L 9.17 8.25
aliquot with BP precaution Refer
05/18 10.52 H 739.08 H
ESRD sec to HTN NSS vs DKD FeSO4 325mg/tab 1 tablet once
05/09 22.23 H 1292.64 H
(-) anuria daily ESRD sec to HTN NSS vs DKD Type 2 DM, controlled
(-) nausea Ferrous + Folate tab 1 tablet Reticulocyte count (06/08/24): 2.3% (H) Still for ultrasound guided IJ catheter insertion, MARF forwarded
(-) easy bruising once daily 12L ECG (06/08/24): NSR, tall T-waves V2-V4 (06/15)
(-) headache EPO 4,000 3x a week post HD COVID rapid antigen test (06/09/2024): Negative
(-) fatigue Sevelamer 800mg/tab, 1 tab q8 Hba1c (6/9/24): 4.11% IM notes (06/15)
(-) drowsiness Sodium bicarbonate 650mg/tab Hepatitis profile (6/8/24) Low salt, low fat, DM, renal diet
1 tab 3x/day HbsAg 0.41 – NONREACTIVE Heplock
06/12 Anti-HCV 0.09 – NONREACTIVE Tx:
1640H 200/80 -> Amlodipine Anti-HBc IgG 1.69 – NONREACTIVE ⁃ Sevelamer 500mg/tab 1 tab OD
10 mg/tab -> 200/80 -> ⁃ EPO 4000 IU SC 3x/week
Anti-HBs 83.06 – REACTIVE
Clonidine -> 200/80 -> ⁃ FeSO4 325mg/tab 1 tab BID
Metoprolol 50 mg/tab -> Coagulation studies
⁃ Ferrous + Folic acid 1 tab OD
180/100 -> Nicardipine drip -> Date PT % Activity INR APTT
Continue medications for now
110/70 06/13 12.2 99.2 1.09 41.7
Awaiting MARF approval for HD access
Facilitate anemia correction
Imaging
Clearance:
CXR (06/17, Osmak) Impression: MRA: Intermediate risk (Dr. Diaz)
Bilateral perihilar and lower lung haziness is noted. Endo: No absolute indication
Pulmonary vascular markings appear accentuated. VSq4h I&Oqshift
Heart is magnified but appears enlarged.
Both sulci appear indistinct.
Hemidiaphragms are intact. Surgery notes (06/16)
The visualized bony thorax is unremarkable. NPO
A left-sided IJ catheter is now seen with its tip at the level of the superior vena. The right-sided IJ catheter is no IVF c/o main service
longer visualized. For IJ insertion left
Noted clearance
Impression: MARF approved
Cardiomegaly with pulmonary congestion. Concurrent bibasal pneumonia is not excluded.
Consider minimal bilateral pleural effusion TCVS (06/15)
CXR (6/9/24, OSMAK) Low lung volume with bronchovascular crowding. Cannot totally exclude pulmonary congestion or beginning Diet and IVF c/o main service
pneumonia. Still for removal of permcath, right; IJ catheter insertion, left –
Probable cardiomegaly awaiting MARF approval
KUB UTZ (05/13/24 Findings: Continue present management
OSMAK) Both kidneys are normal in size with smooth and regular contour.
The cortico-medullary pattern in both sides is intact. Type 2 DM, controlled
Type 2 DM, controlled Insulin glulisine sliding scale The right kidney measures 9 x 3.2 x 3.9 cm with cortical thickness of 1 cm. For CBG monitoring and control
(-) polyphagia 180-220 2u The left kidney measures 9.1 x 3.7 x 3.7 cm with cortical thickness of 1 cm. For CBG TIDACHS
(-) polydipsia 221-260 4u There is no evidence of hydronephrosis, lithiasis or mass noted in both kidneys.
(-) polyuria 261-300 6u
>300 8u The urinary bladder is nondistended. IM Endo notes (06/10)
IMPRESSION: Thank you for this referral
Unremarkable ultrasound of both kidneys Diagnostics: FBS
Nondistended urinary bladder Therapeutics
TVS UTZ (05/10/24, Findings: Insulin glulisine sliding scale
OsMak) Uterus is anteverted and enlarged measuring 9.1 x 7.6 x 7.5 cm (volume of 272 mL). 180-220 2u
Myometrial echopattern is homogeneous. 221-260 4u
No focal mass is seen. 261-300 6u
Endometrial lining is thickened and heterogeneous measuring 2.1 cm. >300 8u
The right ovary is normal in size measuring 3.0 x 1.9 x 2.6 cm (volume of 7.8 mL).
Hypertension St. II, The left ovary is likewise normal in size measuring 2.6 x 2.1 x 2.0 cm (volume of 6.0 mL). HTN St. II, controlled
controlled Amlodipine 10mg/tab 1 tab OD No adnexal mass is noted. For BP monitoring and control
(-) BOV Metoprolol 50mg/tab 1 tab BID The cervix is open and normal in size measuring 3.1 x 2.9 x 3.0 cm. Fluid is seen within the endocervical canal.
(-) headache Clonidine 150mg tab 1 tab every Minimal fluid is seen in the posterior cul-de-sac. Ophtha notes (06/16)
(-) dizziness 6 hours with BP precaution; Impression: Ideally for OFE of both eyes, however patient opted to have it done
(-) chest pain Atorvastatin 40mg/tab 1 tab OD Enlarged anteverted uterus with thickened and heterogeneous endometrium. Tissue correlation is suggested. at OPD
(-) DOB/SOB ISMN 30mg 1 tab OD Open cervix with endocervical fluid Retina service updated.
(-) vomiting Irbesartan 300mg tab 1 tab OD Minimal posterior cul-de-sac fluid For consult with retina service on June 20 (Thurs) 8 AM
Last BP elevation at 06/12 Unremarkable ultrasound of the ovaries Appointment slip given (in case patient is discharge)
2000H 160/90 Chest Xray (05/09, Cardiomegaly Refer back it with new concern.
OsMak)
TVS UTZ (10/12 The anteverted uterus is enlarged and bulky measuring 7.5 x 6.4 x 7.1 cm. Myometrial echopattern is coarsened IM Notes (06/17/24)
Megason) and heterogeneous. Endometrial stripe is thickened measuring 2.1 cm. Cervix is normal with intact canal Tx:
measuring 3.2 x 1.9 x 2.1 cm. 1. Irbesartan 300mg tab 1 tab OD
The right ovary measures 3.2 x 2.2 x 4.1 cm (Vol. 14.8 cc). The left ovary measures 2.8 x 2.1 x 2.8 cm (Vol. 8.6 cc). 2. Amlodipine 10 mg/tab 1tab OD
Multiple subcentimeter peripherally distributed cystic foci are seen in both ovaries. 3. Continue other meds
Multiple electrolyte The posterior cul-de-sac is intact.
imbalance (Hyponatremia, GICS as follows q2 hours x 6 IMPRESSION:
hypochloremia) secondary to cycles (completed 06/10 0200H) Enlarged and bulky, anteverted uterus with coarsened and heterogeneous
ESRD GICS for 6 cycles (2 cycles given myometrium and thickened endometrium. Primary consideration is diffuse uterine adenomyosis; rule out Multiple electrolyte imbalance (Hyponatremia, hypochloremia)
(-) chest pain before IV line was out) endometrial hyperplasia. Tissue correlation is recommended for further evaluation. secondary to ESRD
(-) palpitations Glucose D50-50 1 vial TIV + Normal sized ovaries with polycystic features bilaterally. Please correlate with clinical and laboratory findings.
(-) tremors Insulin HR 10 units TIV CBG monitoring IM Notes (06/17)
Calcium gluconate 10%, 10 ml as Patient seen and examined
Date 0500H 1400H 1720H 2100H
slow IV push-given For HD today with the ff settings
-Salbutamol MDI, 2 puffs now 06/1 103 200 175 UF 4L Qb 250 nonheparinized
Calcium polysterene sulfonate 7 BUR 4h Qd 500 IJ catheter
15g/sachet, dissolve 1 sachet in 06/1 137 122 126 For transfusion of 1 unit pRBC on HD as fastdrip
1/2 glass water now then every
6
8 hrs t/c Hospital Acquired Pneumonia
Metoclopramide 10mg TIV q8 as 06/1 135 153 160 180 IM Pulmo (06/18)
needed for nausea and vomiting 5 Noted CXR findings, last HD 06/12
06/1 120 186 169 205 Will attribute CXR findings to congestion rather than HAP
4 For HD today as ordered
t/c Hospital Acquired
pneumonia 6/13 165 159 161 173
(-) DOB/SOB No meds for now 6/12 138 154 171 179 Proliferative diabetic retinopathy, both eyes Vitreous
(-) cough 6/11 114 179 175 163 hemorrhage, left eye s/p Panretinal photocoagulation, right eye
(-) desaturation
(-) fever 6/10 104 120 151 153 Ophtha Notes (06/11)
6/9 124 136 104 150 Thank you for this referral
Proliferative diabetic Patient seen and examined
retinopathy, both eyes Plan to do dilated fundus examination using tropicamile +
Vitreous hemorrhage, left No meds for now phenylephrine eye drops 1 drop to both eyes every 15 mins for 3
eye s/p Panretinal doses
photocoagulation, right eye Asking for written clearance form main service to do DFE using the
(-) sudden vision loss said eye drops , which may increase blood pressure
(-) eye redness Refer back once cleared for dilated fundus examination
(-) floaters Refer
Visual acuity: 20/20 both eyes Gyne wise

Intact EOMs For anemia correction
Pad count qshift
Continue present management
Gyne wise
(-) hypogastric pain
(-) vaginal bleeding Tranexamic Acid 1g TIV every 8 Advanced directives: YES TO ALL
hours for 24 hours then 500mg 1
Nulligravid tab every 8 hours as needed for Contact number of relative: 09055692214
LMP: May 3-present vaginal bleeding
PMP: March last week to April Paracetamol + Tramadol
second week 325mg/37.5mg/tab 1 tab every
PMP: February 1st week 8 hours as needed for pain
PMP: Nov 6-present
(4overnight pads, moderately
soaked)
PMP: Sept 20, 2023- October
3rd week
PMP: third week of august
PMP: 3rd week of July 2023
Abdomen flabby, no
tenderness on light/deep
palpation on all quadrants, no
muscle guarding
Normal looking external
genitalia, parous introitus
SE: cervix pinkish measures
3x3 cm, no lesions, no polyp,
(+) scanty bleeding per os
IE: vagina admits 2 fingers
with ease,
cervix closed, no cervical
motion tenderness, no
adnexal mass/tenderness,
uterus enlarged to 16 weeks
AOG
RVE: intact sphincteric tone,
smooth rectovaginal septum,
rectal vault not collapsed, no
nodulations, with smooth and
pliable bilateral parametria
Pad count: 1 pad (spotting)

REFERRALS
704 G3P3 (3003) BP 110/70 TCR of 1000kcal DAT CBC
PICONES, JOSEL PASCUAL Cervical Carcinoma HR 98 divided into 3 meals and 2 Date Hgb Hct WBC S L M E Plt
32 (POORLY RR 20 snacks with Ensure 6 06/16
YC DIFFERENTIATED) St IIB T 37.7 scoops in 200ml water s/p BT 10.2 0.30 15.1 94 3 3 486
S/P Brachytherapy x 4 IVF B fluid 1L x 24 hrs of 6u
(May, 2024) I: 3267 06/14 9.6 L 0.29 L 14.0 94 H 2 4 514 H
61564 s/p Radiotherapy x 28 O: 3200
Date Admitted: 05/10/2024 06/13 8.7 L 0.27 L 13.7 H 91 H 6 3 580H
fraction
Date Referred: 05/24/2024 06/08 10.2 L 0.31 L 18.5 H 92 H 3 5 596 H
s/p Chemotherapy x 4 Ht: 47 kg
Dr. Santos, Odevilas/Tungcul, 05/25 13.3 0.39 14.5 91 H 4 4 1 515 H
cycles (Dec 18 2023, Jan Wt: 150 cm
de Paz, Ballesteros/ Reyes (TL)/ 05/22 10.5 L 0.31 L 16.5 H 93 H 5L 2 581 H
14 2024) BMI: 20 kg/m2
Tugado, Gallano/ Alzaga, Vito Persistent/Progressive 05/19 8.7 L 0.26 L 16.0 H 94 H 2L 4 603 H
Disease (Bone Metastasis) Paracetamol 500mg tab 1 05/15 9.2 L 0.28 L 10.4 92 H 6L 2 529 H
Fracture, closed, tab every 6 hours 05/13 8.9 L 0.26 L 11.2 90 H 3 6 1L 447 Fracture, closed, comminuted, displaced,
s/p Cervical punch biopsy comminuted, displaced, Tramadol 50mg TIV every 05/10 11.3 L 0.34 L 10.5 90 H 4L 5 1L 513 H subtrochanteric femur, left
(09/25/2023) subtrochanteric femur, left 8 hours O+/NR Superolateral dislocation, patella, left
Superolateral dislocation, Celecoxib 200mg cap 1 Urinalysis Still for reduction possible open application of
Bacterial Vaginosis, patella, left cap BID Date Sugar Protein WBC RBC Epithelial Bacteria intramedullary nail, left femur.
resolved (-) DOB/ SOB calcium carbonate + Vit 06/08 NEG 2+ 245.4 13.1 4.1 71.5
Blood transfusion of 6 (-) fever, last episode: D3 200mg/tab, 2 tabs OD 05/23 NEG NEG 2-4 3-5 FEW FEW Surgery Notes (06/17/24)
units pRBC for anemia 1725H 06/01, 39.0 -> Morphine 10mg/tab,1 tab Diet as ordered
05/19 NEG Trace 8-10 H 2-4 FEW FEW
moderate secondary to Paracetamol 1 g TIV -> 37.3 every 8 hours round the Adequate analgesia
05/13 NEG Trace 1-3 0-2 FEW FEW
malignancy, corrected (+) foam boot traction in clock. Rescue dose of For urine CS as ordered by ortho
Coagulation studies
Fracture, closed, place, left Morphine 10mg/tab, 1/2 Noted palliative schedule for family meeting 06/18
Date PT % Act INR APTT
comminuted, displaced, tab as needed for patient. 06/13 13.6 88.3 1.22 40.5 1 PM RIC informed
subtrochanteric femur, Paracetamol 1g TIV every
05/25 13.4 90.1 1.2 39.8
left 4 hours round the clock Ortho Notes (06/17/24)
05/22 14.0 84/8 1.26 H 40.2
Zolendronic acid 4mg by Dr. Lim updated
05/10 12.9 94.0 1.15 41.3
Superolateral dislocation, SIVPx 15mm 3x/week- For urine CS
patella, left HOLD (06/03/24) Chemistry
Enoxaparin 400 SQ once Date BUN Crea Mg Albumin Na K AST ALT HbA1c CL iCa Total Ca
Previous Emergency Low daily – HOLD 06/13 5.42 42.25 129.27 L 3.8 Anesthesia Notes (05/30/24)
Transverse Cesarean 06/03 32.42 0.65 L 27.94 L 131.06 L 4.04 95.42 L 1.38 2.34 Thank you for this referral
Section I for abruptio 05/30 132.83 Patient seen and examined
placenta over GETA 05/25 4.36 History and PE done
(5/22/23) 05/22 31.98 L 0.78 31.52 131.43 L 4.33 24.45 26.60 5.16% Labs noted
05/15 44.98 L 131.21 L 4.20 Anesthesia plans, risk and complications explained
to and fully understood by the patient
05/14 0.59 L
NPO 8 hours prior to wheel-in
05/13 5.11 37.86 L 128.55 L 4.67
IVF: PNSS 1L x KVO rate to hook prior to OR
05/10 5.98 44.23 L 33.44 L 129.04 L 5.37 H 55.98 H 44.92 H
Medications:
Vaginal Discharge GS (05/24/24): SMEAR SHOWS PRESENCE OF GRAM NEGATIVE COCCOBACILLI, MODERATE LEUKOCYTES AND EPITHELIAL CELLS 1. Omeprazole 40mg IV once a day
Vaginal Discharge KOH (05/24/24): NEGATIVE 2. Paracetamol 1g IV 1 hour prior to OR
ECG (05/24): Normal sinus rhythm 3. Tramadol 50mg + 9ml PNSS via slow IV push
D-dimer (06/13): 1556.83 H every 8 hours as needed for moderate and severe
Imaging pain.
Chest xray (06/16, OsMak) - No distinct evidence of pulmonary embolism Secure 2nd IV line (g18 or g 20) on the contralateral
- Minimal fibrosis or atelectasis, left lower lung arm then shift to helpock
- Trace pleural effusion, left Secure 2 units Prbc properly typed and
- Calcified left hilar lymph nodes crossmatched prior to OR
- Multiple rib and vertebral lytic-sclerotic changes as discussed and hypoenhancing hepatic lesion, worrisome for For serum Na correction (>= 135mmol/L –
metastatic disease 145mmol) prior to OR
-The partly visualized prominent sized left kidney with calyceal fullness Will refer this case to our service consultant
Chest xray (06/13, OsMak) No significant cardiopulmonary findings Check CBG and VS prior to wheel-in. Inform at
Lucent lesions, right 8th lateral rib. Consider bone metastasis in light of patient’s known malignancy. local1416.
Chest xray (06/07, Osmak) No significant chest findings Suggest sodium correction prior to OR, but if
Bone Imaging (MMC, 5/7/24) Clinical Data: Patient was diagnosed with poorly differentiated carcinoma of the cervix (2023) and underwent benefits outhweight the risk may proceed with
chemotherapy and radiotherapy. (+) left femoral fracture. contemplated rooms
Technical Report: Whole body scans in the anterior and posterior views were obtained 3 hours after injection of 466
MBq (12.6 mCi) of Tc-99m MDP. Dual intensity images were produced and SPECT was performed from the head to IDS Notes (05/24/24)
mid-thigh. Noted urinalysis results, no symtptoms of dysuria,
Scintigraphic Findings: hematuria, flank pain
There is satisfactory skeletal labeling. Both kidneys are visualized. Fever may be attribute to known malignancy
Increased tracer accumulation in the proximal third of the left femur, corresponds to the known fracture. process
Foci of increased tracer uptake are seen in the following: IDS wise will not treat as CUTI
- anterior segment of the 8th right rib Respectfully signing out of this case.
- posterior segment of the 7th left rib
- T6 and T11 vertebra Anemia moderate secondary to malignancy,
- sacrum corrected
- left ilium s/p BT of 6u pRBC
The rest of the visualized skeletal structures show symmetrical and physiologic tracer distribution.
Impression:
Increased osteoblastic activity in the areas described above is consistent with bone metastases. Surgery Notes (06/16/24)
ARI Bed 5 G2P2 (2002)
FRANCIA, LYNETTE BUENAVISTA Squamous cell carcinoma large cell keratinizing cervix stage IIB
65 s/p Cisplatin VI (October 27 2017, MMC)
YC S/P External Beam Radiation Therapy (TOMO) x 28 doses (October 27, 2017, MMC)
S/P High-Dose Rate (HDR) Brachytherapy x 4 doses
Date admitted 05/20/2024 Tumor recurrence (spine, paracaval and left common illac nodes)
Date referred: 05/20/2024 AKI on top of CKD sec to
1) Obstructive Uropathy from Cervical CA Stage II B
3771612 2) Infection (Complicated UTI)
Dr. Alfabeto/Tungcul, Go/ Reyes(TL)/ Pesigan, Posadas/Jasarino Complicated UTI
Hyperkalemia prob secondary to CKD
Hypovolemic hypoosmolar hyponatremia prob secondary to poor oral intake
Hematuria prob secondary to Cervical Ca with bladder extension
S/p Cystourethroscopy with removal of foreign body, calculus or ureteral stent from urethra or bladder; Cystoscopy, evacuation of blood clots, fulguration (Feb
3, 2024)
SLE, in flare SLEDAI 12
T/C Autoimmune hemolytic anemia
T/c G6PD deficiency
Hypertension Stage II
ICU psychosis, resolved
Bronchial Asthma, well controlled
s/p PTB treatment for 1 year (1994 PGH)
ICU 513 G2P1 (1011)
QUIJANO, ROSA GABINETE Endometrioid carcinoma, endometrium St. IB
77 Persistent Tumor Recurrence (2022, OSMAK)
YC
Previous Exploratory Laparotomy, Peritoneal Fluid Cytology
285568 Extrafascial Hysterectomy with Bilateral Salpingooophorectomy with Bilateral Pelvic Lymph Node Dissection, Paraaortic Lymph Node Evaluation Adhesiolysis
Date referred: May 21, 2024 (2017-06-21, OSMAK)
Date admitted: May 21, 2024 S/P Brachytherapy x 4(2017, Cardinal Santos)
Dr. Santos/Tungcul, Ballesteros, De Paz (TL)/Gallano, Tugado/Alzaga, Vito NED x 4 years
S/P Chemotherapy Paclitaxel x 3 (May-Jul, OSMAK 2022)
Infected Sacral Decubitus Ulcer, unstageable

Hypovolemic hypoosmolar hyponatremia sec to poor oral intake
Acute Respiratory Failure secondary to CAP HR
AKI secondary to 1.) Infection 2.) Dehydration from suboptimal intake on top of CKD Stage IIIB probably from HTNSS
Hypovolemic Hypoosmolar Hyponatremia probably secondary to dehydration
Hypokalemia secondary to AKI
Anemia secondary to 1) Chronic illness 2) AUB sec to Endometrioid carcinoma, endometrium, St. IB; Tumor Recurrence
Sacral Decubitus Ulcer, Stage III
Hypertension Stage II, controlled
s/p CVD Infarct, Left MCA Territory, NIHSS 17, modified Rankin Score 4 (moderately severe disability, rule out Brain Metastasis)
T/c Rectovaginal Fistulas/p Wound debridement sacral ulcer (4/14/2024)
s/p Transverse Loop Colostomy (5/10/24)
Prolonged intubation, Subglottic stenosis secondary to prolonged intubation

s/p Tracheostomy; Direct Laryngoscopy with Intralesional Steroid Injection (06/03/24)
ARI 2 Bed 5 G8P8(8008)

LISONDRA, FLAVIANA CUISON Pelvic Organ Prolapse St. IV
77 Menopause for 23 years
NYC CVD Bleed (27.4cc) Frontoparietal Area, Right NIHSS 6 ICH: 0
Hypertension St. II
3873304 Seizure prob sec to CVD Bleed
Date Admitted: 06/10/2024 Hypovolemic Hypoosmolar Hyponatremia prob Suboptimal Intake
Date Referred: 06/10/2024 Asymptomatic Bacteriuria
Dr. Palomares/Tungcul/ Gavino (TL)/ de Guia, Posadas/Tiongson, S/P CVD Infarct, Left Sided Residual (2020)
Kadappurath

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OSPITAL NG MAKATI

Sampaguita corner Gumamela St., Brgy. Pembo, Makati City, Philippines

ADMISSIONS OB WARD LR / DR GYNE WARD PERIPHERALS REFERRALS

OB 1 G3P3 (3003) Pregnancy BP 110/70 DAT CBC with PC EINC

OB 11 G1P1 (1001) Pregnancy BP 110/70 DM diet CBC with PC EINC

OB 15 G5P4 (4004) Pregnancy BP 120/70 DM diet + high potassium CBC with PC

Previous total thyroidectomy Levothyroxine 150mcg/tab

Pad count: 1 pad moderately

OB 9 G2P2(2002) Pregnancy uterine BP 90/60 DAT CBC with PC EINC

OB 11 G3P2 (2012) BP 110/70 DAT CBC with PC -

OB 16 G2P1(1001) PU 12 4/7 weeks BP 110/70 NPO CBC with PC

Hyperemesis gravidarum Metoclopromide 1amp TIBV

OB Wise Folic acid 10 mg/tab 1 tab OD OB Wise

abdomen flat soft nontender

Last episode of BP elevation: IM Nephro (06/17)

[ ] For lipid profile 06/18

Mid-Calf, R Mid-Thigh, R Mid-Calf, L Mid-Thigh, L

OB wise ABG Hypokalemia secondary to poor

Perinatology Notes (06/17/24)

Surgery Intraoperative findings – Emergency Exploratory Laparotomy (06/17)

Surgery Intraoperative findings – Ultrasound-guided IJ catheter insertion, Right (06/17)

Anes Notes (06/17)

Gyne 6 Nulligravid BP 100/60 NPO CBC with PC

Visual acuity: 20/20 both eyes Gyne wise

Pad count: 1 pad (spotting)

Infected Sacral Decubitus Ulcer, unstageable

Prolonged intubation, Subglottic stenosis secondary to prolonged intubation

ARI 2 Bed 5 G8P8(8008)

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