Endorsement Census - June 10, 2024 V2

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 10, 2024
(MONDAY)
ADMISSIONS OB WARD LR / DR GYNE WARD PERIPHERALS REFERRALS

LRDR DE LA CRUZ-GALICIA, LORIEDIN AVISO OB 1 GOMEZ, ALYANNA ADRIANNE VILLANUEVA Gyne 1 ESCIETE, MARIAFE GARA SARI 3 BED 3 LIPARDO, MARY GRACE CASTA 704 PICONES, JOSEL PASCUAL
HR2 MANIEGO, MARIANE MARTIREZ OB 8 ARMEÑA, ANTHONETTE LASAT Gyne 2 HILARIO, AILEEN MENDOZA BED 1 IW PILAPIL, MILAGROS BALMORI
Gyne 7 AWID, DOLORES VICTORIA SAN OB 9 BALADIA, CRISCHELLE LAVA Gyne 3 ALTA, MARIA SALOME ASENETA ARI Bed 5 FRANCIA, LYNETTE BUENAVISTA
Referral ARI 2 Bed 5 LISONDRA, FLAVIANA OB 13 BOHOLST, PRINCESS SORIANO Gyne 4 ADRIATICO, ROWENA DE LA REA ICU 513 QUIJANO , ROSA GABINETE
CUISON OB 17 LOMBOY, MICHELLE PANICAN Gyne 5 LOMBOY, MICHELLE PANICAN
OB 19 GAERLAN, LOLITA GA Gyne 6 LOPEZ, QUEYZEE ROLDAN
OB 20 PAULINO, CHERIZZE FACUNDO
HR 3 GOYALA, MARITES ESPINAS
HR 5 CABUENAS, JENELYN ABEÑON
ADMISSION
PATIENT INFORMATION DIAGNOSIS SUBJECTIVE/OBJECTIVE THERAPEUTICS LABORATORIES PLAN/NOTES Remarks
LRDR G1P0 Pregnancy Uterine 35 BP 100/60 DM diet, NPO once in CBC with PC
DE LA CRUZ-GALICIA, LORIEDIN 6/7 weeks AOG cephalic in HR 80 active labor Date Hgb Hct WBC S L M E Plt
AVISO preterm labor RR 20 IVF: Heplock 06/10 13.4 0.39 12.8 78 15 6 1 203
30 Gestational Diabetes T 36.6
O+/R
NYC Mellitus, newly diagnosed O2 98%
Urinalysis
Bacterial vaginosis
Date Sugar Protein WBC RBC Epithelial Bacteria Leukocyte
3932306 Chronic Hepatitis B Gestational Diabetes Mellitus, Insulin sliding scale: Gestational Diabetes
06/10/2024 infection, low infectivity newly diagnosed Regular insulin 06/10 Neg Neg 0.5 6.1 20.3 3.1 Neg Mellitus, newly diagnosed
Dr. Palomares/Tungcul, (-) polyphagia 110-150: 2 units Ferritin (06/10/24, OSMAK): 45.37 For 7pt CBG monitoring
Ballesteros(TL)/ Gavino/ de (-) polydipsia 151-200: 4 units Imaging
Guia, Posadas/Tiongson (-) polyuria 201-250: 6 units SLIUP Cephalic 35 3/7 weeks AOG EFW 2672g FHR 130 IM Endo notes (06/10)
BPS UTZ (06/10/24 OSMAK)
See CBG table 251-300: 8 units Fundal placenta, grade II AFI 9.7 cm SDP 5 cm BPS score 8/8 STRAT Insulin sliding scale
>300 10 units SLIUP Cephalic 32w1d 145 bpm 2017g AFI:13.9 SDP: 3.84 CBG every 4 hours – not
BPS UTZ (05/13/24, Precious Ultrasound and Diagnostic)
Posterior High-lying Placenta Grade II-III BPS 8/8 carried out, still for 7pt
SLIUP 22 2/7 weeks AOG Breech 145 bpm CBG targets 70-110 mg/dL
CAS (03/09/24) Normohydramnios 498g Posterior HL gr I Refer back once at OB ward
NO SONOLOGIC EVIDENCE OF FETAL ANOMALY SCAN
Bacterial vaginosis Metronidazole 500 mg/tab 75g OGTT (05/04, Megason) @ 21w6d
(-) foul smelling discharge 1 tab every 12 hours for 7 FBS 99 H
(-) whitish vaginal discharge days 1st hour 167.4 Bacterial vaginosis
2nd hour 153 H Completion of antibiotics
Hba1c (06/10): 5.11
Vaginal discharge GS (06/10/24): GRAM POSITIVE LACTOBACILLI WITH MANY LEUKOCYTES, EPITHELIAL CELLS AND PRESENCE OF OCCASIONAL GRAM NEGATIVE BACILLI.
Chronic Hepatitis B infection, Vaginal discharge KOH (06/10/24): Negative Chronic Hepatitis B infection,
low infectivity No meds for now Chemistry: low infectivity
(-) jaundice Date AST ALT Referred to IM Gastro (Dr.
(-) RUQ pain Manayon)
06/11 37.03 H 27.80
(-) tea colored urine
Hepatitis profile (06/11/24)

OB wise Ferrous sulfate 325mg/tab HbsAg REACTIVE
OB wise
Good fetal movement 1 tablet once a day Anti-HAV NONREACTIVE For tocolysis, dexamethasone
(-) watery vaginal discharge Multivitamins 500mg/tab 1
Anti-HAV IgM NONREACTIVE completion, and workup of
(-) bloody vaginal discharge tablet once a day
Anti-HCV NONREACTIVE infection
(-) perceived irregular uterine Calcium carbonate
PROD informed(Dr. Ortiz),
contractions 500mg/tab 1 tablet 2x/day Anti-HBc IgG REACTIVE with availability of incubator
Isoxsuprine 10mg/tab 1 Anti-HBc IgM NONREACTIVE For NST BID
G1P0 tab 3x daily for 7 days
HbeAg REACTIVE Strict FHT q4 and record
LMP: Oct 4 , 2023 Dexamethasone 6mg TIM
Anti-HBs NONREACTIVE Fetal kick monitoring
35 6/7 weeks AOG by LMP every 12 hours to
For complete perineal
36 2/7 weeks AOG by UTZ complete for 4 doses Anti-Hbe REACTIVE preparation
(Nov 17, 6w5d) (2 out of 4 given)
IE only if with indication
1st dose: 06/10 1410H CBG monitoring
Globular abdomen 2nd dose: 06/11 0200H Date 0500H 1900H 2100H
FH: 31cm 3rd dose: 06/11 1400H 06/11 120
EFW 4th dose: 06/12 0200H 06/10 133 109
- Johnson’s rule: 2945 g
- Cupping method: 3000 g Tracing
FHT: 140s Date Interpretation BFHT Variability Acceleration Deceleration Contraction
IE: cervix 3 cm dilated, 30%
effaced, intact BOW, cephalic, 06/11 AM Reactive 130-135 Moderate (+) (-) No contraction
station -3 06/10 PM Reactive 130-135 Moderate (+) (-) No contraction
06/10 AM Reactive 130-135 Moderate (+) (-) No contraction
06/10 AM Moderate
Reactive 130-135 (+) (-) No contraction
Post terb
06/10 AM Moderate 2 moderate to strong
Cat I 140-145 (+) (-)
OB OPD contractions in 10min
HR 2 G2P1 (1001) PU 25 3/7 BP 110/70 DAT CBC with PC
MANIEGO, MARIANE weeks AOG cephalic not in HR 95 IVF: PNSS 1L x 30cc/hr for Date Hgb Hct WBC S L M E Plt
MARTIREZ labor RR 20 1 cycle then shift to 06/11 12.1 0.37 21.1 H 86 7 7 293
21 Acute pyelonephritis T 37.2 heplock
_+/NR
Ferritin (06/10/24, OSMAK): 78.07
3924494 Previous appendectomy
Urinalysis
06/10/2024 (2017, Sta. Ana Hospital)
Dr. Palomares/Tungcul, de Paz
(TL)/Gavino/ de Guia, Acute pyelonephritis Ceftriaxone 2g IV OD ( ) 06/11 Neg Trace 122.7 H 1.2 20.3 7330.8 H 2+
Posadas/Tiongson (+) dysuria ANST Chemistry:
(-) urgency Paracetamol 300 mg TIV Date BUN Crea Hba1c Na K
(-) frequency every 6 hours for 24 hours 06/11 2.69 51.91 - 133.52 L 4.48 Acute pyelonephritis
(+) right flank pain Vaginal discharge GS (06/11/24): SMEAR SHOWS PREDOMINANCE OF GRAM POSITIVE LACTOBACILLI WITH FEW LEUKOCYTES AND MANY EPITHELIAL CELLS For repeat UA after D3 of
(+) fever Vaginal discharge KOH (06/11/24): Negative antibiotics
TSR urine CS (06/10)
06/11 0900H Referred to IM Nephro (Dr.
39.4 -> Paracetamol 600 mg Imaging Vizcaya)
TIV -> 37.0C Bilateral moderate hydronephrosis
Multivitamins 500mg/tab 1 KUB Utzi 06/11 c/o Dr. San Pedro no lithiasis
OB wise tab once a day underdistended bladder
Good fetal movement Ferrous sulfate 325mg/tab Pelvic Utzi 06/11 c/o Dr. San Pedro SLIUP cephalic 27w2d 148bpm EFW 1058g SDP 8.23 AHL, g1
(-) watery vaginal discharge 1 tab once a day OB wise
Findings:
(-) bloody vaginal discharge Calcium 500mg/tab 1 tab For medical management
(-) perceived irregular uterine 2x a day PROD informed (Dr. Almario)
Within an enlarged ante uterus, measuring 8.07 x 7.81 x 6.68, is a single
contractions Monitor vsq4, FHTq4 and
gestational sac measuring 4.34 x 1.87 x 4.36. An embryo is seen with a
record
crown rump length of 1.81 cm compatible with 8 weeks and 2 days age of
G2P1 (1001)
gestation.
LMP: November 14, 2023 [ ] TSR ABO – 06/11 AM
AOG: 30 weeks [ ] For CAS – to secure sched
Good cardiac activity noted at 168 beats/min.
25w3d AOG by UTZ next week (will inform Dr.
(02/12; 8w2d) Gallano)
Yolk sac is seen with a diameter of 0.3 cm.
Slightly globular abdomen
Minimal subchorionic hemorrhage is seen (approximately 0.97 cc).
(+) CVA tenderness
(+) Kidney punch
Cervix is long and closed, measuring 4.16 x 3.74 x 2.78. No focal lesions
identified or funneling noted.
FH: 22 cm
TVS UTZ (02/12, Osmak)
FHT: 120s
The right ovary is normal in size measuring 2.63 x 1.36 x 2.22 (4.14 cc).
IE: cervix closed
The left ovary is likewise normal in size measuring 2.12 x 2.08 x 1.52 cm
(3.51 cc).
No evidence of adnexal mass.
No definite evidence of fluid seen in the posterior cul-de-sac.
Impression:
Single live intrauterine pregnancy compatible with 8 weeks and 2 days age
of gestation by crown lump length.
Minimal subchorionic hemorrhage.
Normal sized ovaries.
Normal cervix. No evidence of adnexal mass.
No evidence of posterior cul-de-sac pathology.
TVS UTZ (1/18/24, OSMAK) Within an enlarged anteverted uterus, measuring 7.3 x 5.7 x 6.5 cm, is a
single gestational sac measuring 0.72 x 0.58 x 0.94 cm with a mean sac
diameter of 0.75 cm compatible with 5 weeks and 3 days age of gestation.
No embryo seen. No yolk sac appreciated.
No subchorionic hemorrhage is seen.
Cervix is long and closed, measuring 2.7 x 2.3 x 2.9 cm. No focal lesions
identified or funneling noted.
The right ovary is normal in size measuring 1.6 x 1.1 x 2 ( 1.9 ml).
The left ovary is likewise normal in size measuring 3.4 x 2.2 x 2.4 (9.5 ml).
A cystic focus is seen within the left ovary measuring 1.4 x 1 x 1 cm.
No evidence of adnexal mass.
No definite evidence of fluid seen in the posterior cul-de-sac.
Remarks:
Consider early intrauterine pregnancy compatible with 5 weeks and 3 days
age of gestation by mean sac diameter. Follow-up after 2 weeks is
suggested for viability of pregnancy.
Normal sized ovaries with probable corpus luteum on the left.
Normal cervix. No evidence of adnexal mass.
No evidence of posterior cul-de-sac pathology.
Gyne 7 G3P3 (3003) BPR 120/80 NPO CBC with PC
AWID, DOLORES VICTORIA SAN Uterine myoma BP 120/80 IVF: D5LR 1Lx 30gtts/min Date Hgb Hct WBC S L M E Plt
JUAN Menopause x 24 years HR 84 06/10 13.4 0.38 4.7 61 29 8 2 202
73 Hypertension St II RR 20
O+/NR
YC Bronchial asthma not in T 36.7
Urinalysis
acute exacerbation
3911170 Obese I I: 1000 (8hrs)
06/10/2024 s/p Cholecystectomy (2009, O: 600 (8hrs) 06/10 Neg Neg 2.2 6.0 14.5 4.0 Neg
Dr. Odevilas/Tungcul, de Paz UERM) Chemistry:
(TL)/ Gavino/ de Guia, Ht: 65.6kg Date BUN Crea BUA Na K Cl AST ALT
Posadas/Tiongson, Kadappurath s/p Dilatation and Wt: 154.5cm 06/11 4.57
endometrial biopsy under BMI: 27.5kg/m2 (Obese I)
0801H/0818 SAB (06/11/2024) 06/11 3.25 L
EBL: minimal blood loss 06/10 4.27 53.09 141.74 3.43 L 103.69 24.36 26.19
Coagulation studies
Hypertension St II Losartan 100 mg/tab 1 tab Hypertension St II
(-) headache OD Date PT % Activity INR APTT BP monitoring and control
(-) dizziness Amlodipine 10 mg/tab 1 06/10 11.2 107.7 0.99 38.3
(-) nape pain tab OD Ferritin (06/10/24, OSMAK):
(-) chest pain 12L ECG (06/10/24, OSMAK): Normal sinus rhythm
(-) DOB/SOB 12L ECG (05/14/24, OSMAK): Poor R wave progression Hypokalemia secondary to suboptimal intake,
Imaging corrected
Cardiomegaly No active management
Hypokalemia secondary to KCl drip: 20 meqs in 80 cc Chest xray (06/10/24) Atherosclerotic aorta IM Nephro notes (06/11)
suboptimal intake, corrected PNSS every 4 hours for 3 Mild degenerative osseous changes KCl drip: 20 meqs in 80 cc PNSS every 4 hours
(-) weakness cycles -d/c TVS UTZ c/o OB sono (4/15/24) The uterus is enlarged and lobulated as measured with well-circumscribed for 3 cycles
(-) numbness of extremities KCl 750 mg/tab 2 tabs heterogenous myoma as described below, with color flow compatible with Continue KCl 750 mg/tab 2 tabs every 4 hours
(-) chest pain every 4 hours for 3 cycles - myoma for 3 cycles
d/c My1: anterior low segment intramural myoma 3.4x3.86x2.81cm (19.3ml) Repeat K 5 am today - done
KCl 750 mg/tab 2 tabs (FIGO 4)
every 4 hours for 2 cycles – My2: posterior low subserosal, <50% intramural myoma nodule measuring
completed 2.47x2.43x2.87cm (9.0ml) (FIGO 6)
MY3: posterior upper segment submucosal,intramural and subserous
myoma, with cystic degenerative changes measuring 6.96x 6.86x 7.09cm
(177.3ml) (FIGO 2-5) Bronchial asthma not in acute exacerbation
Endometrium: 0.78, hyperechogenic IM Pulmo (06/10)

Bronchial asthma not in acute Salmeterol + Fluticasone The endometrium is thickened as measured, hyperechogenic, non- No objection of contemplated procedure
exacerbation 25mcg/ 125mcg MDI 2 uniform, with multiple irregular cystic structures, with no well-defined (ARISCAT lowrisk)
(-) dyspnea puffs 2x a day endometrial midline, ' Continue Salmeterol + Fluticasone 25mcg/
(-) shortness of breath with irregular endometrial-myometrial junction (posterior endometrium), 125mcg MDI 2 puffs 2x a day
(-) cough with minimal color on color flow studies, findings suggestive of an
Last attack: 2010 Endometrial pathology, with non-benign sonomorphologic features.
Gyne wise
Gyne wise Evening primrose oil gel Cervix 2.82 x 2.62 x 2.20 cm For discharge today
No profuse vaginal bleeding cap, 4 caps every 6hrs per RO not visualized [ ] Histpath sample for send out – amenable,
No severe hypogastric pain vagina LO 4.43 x 4.22 x 3.57 cm 35 cc ACE pateros
cystic, unilocular, thin-walled and anechoic with absence of color on color MRA notes (06/10)
G3P3 (3003) flow studies, findings suggestive of an Ovarian cyst, left with benign MRA: will give final
Menopause x 24 years sonomorphologic features by IOTA simple rules
Anes notes (06/10)
SE: Cervix pinkish, (-) blood Impression: NPO 8 hours prior to OR
clots per Enlarged anteverted uterus with multiple myomas as described For CBG and VS prior to wheel in to DR, to
os,(-) active bleeding per os, Thickened endometrium Endometrial pathology, with non-benign inform AROD at local 1416
no lesions sonomorphologic features Will refer this case to our service consultant
Non-visualized right ovary
IE: vagina admits 2 fingers with Cystic ovary, left
ease, cervix is flushed to the Suggest correlation with clinical presentation and other diagnostic exams.
vault, No Suggest serum tumor marker correlation.
cervical motion tenderness, no
adnexal The uterus is anteverted, with lobulated contour and asymmetrical
mass/tenderness myometrial walls with heterogeneous echopattern. It measures 8.60 x
8.26 x 7.36 cm (corpus only). There are three (3) well-defined, myometrial
RVE:no skin tags, no anal masses of varied echogenicity seen:
fissures, (+) (1) Anterior lower corpus, intramural, measuring 0.90 x 1.03 x 0.94 cm
good sphincteric tone, no (FIGO grade 4)
mass, free bilateral (2) Posterior mid corpus, > 50% intramural with submucous component,
parametria, no blood per measuring 2.93 x 2.65 x 2.63 cm (FIGO grade 2)
examining finger (3) Occupying the posterior myometrial wall and appears to be a
conglomerate of masses, > 50% intramural with subserous component,
Pad count: 0 measuring 6.83 x 7.78 x 4.52 cm (FIGO grade 5)
The endometrium has a thickness of 0.47 cm, is uniform, and is
hyperechoic with minimal anechoic intracavitary fluid seen at the fundal
TVS/TRS/TAS UTZ (12/22/2023, Makati Life) area. The endometrial midline is not defined. The endo-myometrial
junction is interrupted posteriorly by the submucous component of the
previously described myometrial mass. There is no color flow on color flow
mapping.
The cervix measures 2.55 x 2.98 x 2.63 cm.
The right ovary is not seen in this scan (transvaginal and transabdominal
route), probably obscured by bowels.
The left ovary is not seen in this scan (transvaginal and transabdominal
route), probably obscured by bowels.
The cul-de-sac is smooth with no free fluid.
Impression:
- Enlarged, anteverted uterus with myoma uteri
- Thin endometrium with intracavitary fluid as described
- Non-visualized ovaries
Intraoperative findings:
Initial hysterometry: 11 cm
Proceeded to curettage using blunt and sharp curette until frothy and gritty
Obtained a scanty amount of pinkish to dark reddish, non-foul smelling, non-necrotic tissues
Final hysterometry: 11 cm
Estimated blood loss: minimal
Referral G8P8(8008) BPR 110-130/70-90 NPO for now; Once CBC with PC
ARI 2 Bed 5 Pelvic Organ Prolapse St. IV BP 130/80 resume start on Diet: TCR Date Hgb Hct WBC S L M E Plt
LISONDRA, FLAVIANA CUISON Menopause for 23 years HR 80 of 1500kcal/day (Sf 25 x 06/10 12.2 0.36 9.8 74 21 5 294
77 CVD Bleed (27.4cc) RR 20 60kg) using low salt, low
O+/NR
NYC Frontoparietal Area, Right T 36.9 fat diet divided into 3
Urinalysis
NIHSS 6 ICH: 0 meals and 2 snacks with
3873304 Hypertension St. II I: 2200 the ff. macros:
Date Admitted: 06/10/2024 Seizure prob sec to CVD O: 3600 (5.37) CHON 60g 240kcal 06/10 Neg Trace 10.7 1.5 15.1 15122.0 H Neg
Date Referred: 06/10/2024 Bleed 16% Chemistry:
Dr. Palomares/Tungcul/ Gavino Hypovolemic Hypoosmolar Wt: 60kg CHO 189g 756kcal 50.40% Date BUN Crea BUA Na K Cl AST ALT
(TL)/ de Guia, Hyponatremia prob Ht: 152cm Fats 56g 504kcal 33.60% 06/10 4.69 57.76 128.42 L 4.17
Posadas/Tiongson, Kadappurath Suboptimal Intake BMI: 26 - IVF: PNSS 1L x 60cc/hr
Asymptomatic Bacteriuria O2 support at 2LPM NC as Coagulation studies
S/P CVD Infarct, Left Sided supportive for now Date PT % Activity INR APTT
Residual (2020) 06/10 11.8 102.4 1.05 28.6 L CVD Bleed (27.4cc) Frontoparietal Area, Right
COVID-19 RAT (06/10/24, OSMAK): Negative NIHSS 6 ICH: 0
12L ECG (06/10/24, OSMAK): Normal sinus rhythm Hypertension St. II
Imaging Seizure prob sec to CVD Bleed
CVD Bleed (27.4cc) Chest xray (06/10/24) Findings:
Frontoparietal Area, Right Standby Nicardipine drip: Linear opacities are seen in the left lower lung. IM notes (06/10)
NIHSS 6 ICH: 0 10mg in 90cc PNSS to run Pulmonary vascular markings are within normal limits. - Please admit patient under the service of Dr.
Hypertension St. II at minimum rate of 5cc/hr, The heart is enlarged. Sarmiento (AP), Dr. Olaivar (Neuro), Dr. Vega
Seizure prob sec to CVD Bleed titrate by +/- 5cc/hr to The aorta is segmentally calcified. (Nephro)
maintain SBP of less than Both hemidiaphragms and costophrenic angles are intact. - Secure consent for admission and
GCS 15, oriented to 3 spheres. 140mHg Osteophytes are seen lining the margins of the visualized spine. management
Intact MSE Mannitol 150cc TIV every 6 - Diet: NPO for now; Once resume start on Diet:
Cerebellar: No nystagmus, hours Impression: TCR of 1500kcal/day (Sf 25 x 60kg) using low
dysdiadochokinesia, dysmetria Citicoline 1g TIV every 8 Subsegmental atelectasis versus fibrosis, left lower lung salt, low fat diet divided into 3 meals and 2
CN hours Cardiomegaly snacks with the ff. macros:
CN I – Not assessed Losartan 50mg/tab 1 tab Atheromatous aorta (1.0) CHON 60g 240kcal 16%
CN II, - Pupils 2-3mm equally once a day Degenerative osseous changes of the visualized spine CHO 189g 756kcal 50.40%
reactive to light Atorvastatin 80mg/tab 1 FINDINGS: Fats 56g 504kcal 33.60%
CN III, IV, VI – (+) Full EOMs tab once a day No evidence of acute intracranial hemorrhage, acute territorial infarct, - IVF: PNSS 1L x 60cc/hr
CN V – Intact V1-V3; Good Omeprazole 40mg TIV focal mass lesion, or mass effect. - Diagnostics
masseter and temporalis tone once a day Enchephalomalacic changes are seen in the right high fronto-parietal [/] PCCT
CN VII – left central facial palsy Lactulose 30mL once a day lobes. Well-defined hypodense foci are appreciated in the right frontal [/] BUN, Crea
CN VIII- Intact gross hearing at bedtime lobe and right lentiform nucleus. [/] PT, PTT
CN XI, X – Uvula at midline; Levetiracetam 500mg TIV Small patchy inhomogeneous white matter hypodensities are seen in both [/] RAT
good swallowing every 12 hours cerebral hemispheres, which may relate to microvascular ischemic [/] Na, K
CN XI – weak shoulder shrug, Diazepam 5mg TIV as changes, non-specific gliosis, or demyelination. [] iCa, Mg, Phos
left needed for frank seizure Midline structures are in place. Ventricles are not dilated. The cisterns and [] Serum Na and Crea OD
CN XII – Tongue at midline, no sulci are slightly prominent. [/] UA
fasciculations There is segmental calcification of the bilateral internal carotid arteries. [] Lipid profile
Motor: Sella / suprasellar, pineal and cerebello-pontine angle regions are [] HbA1c
5/5 | 1|5 preserved. - Therapeutics
5/5 | 3|5 The brainstem and cerebellum show no frank density change. 1.Standby Nicardipine drip: 10mg in 90cc PNSS
Sensory: Intact bony calvarium. to run at minimum rate of 5cc/hr, titrate by +/-
100% | 50% Mucosal thickening is seen in the left frontal and both ethmoid sinuses. 5cc/hr to maintain SBP of less than 140mHg
100% | 80% NECT of the Brain (05/12/21, Osmak) The rest of the paranasal sinuses and mastoids are unremarkable. Layering 2. Mannitol 150cc TIV every 6 hours
Babinski, Left densities are noted in both maxillary sinueses with bubbly secretions. 3. Citicoline 1g TIV every 8 hours
No meningeal signs Convex density is also present in the right maxillary sinus. The native 4. Losartan 50mg/tab 1 tab once a day
ocular lenses are attenuated / absent likely post surgical change. 5. Atorvastatin 80mg/tab 1 tab once a day
Tonsilloliths are identified in both faucial tonsils, likely post inflammatory. 6. Omeprazole 40mg TIV once a day
7. Lactulose 30mL once a day at bedtime
Impression: 8. Levetiracetam 500mg TIV every 12 hours
- No acute territorial infarct, acute intracranial hemorrhage, focal mass 9. Diazepam 5mg TIV as needed for frank
lesion, or mass effect seizure
- Encephalomalacic changes, right high fronto-parietal lobes, likely from a 10. Losartan 100mg/tab 1 tab once a day
previous vascular insult (i.e. chronic infarct or hemorrhage) - Hook to O2 support at 2LPM NC as supportive
- Chronic lacunar infarcts, right frontal lobe and right lentiform nucleus for now
- Microvascular white matter ischemic changes, non-specific gliosis, or - VSq1 including NVS and record
demyelination in both cerebral hemispheres - I&O qshift
- Cerebral volume loss -- CBG every 6 hours for now since on NPO
- Atherosclerotic vessel disease then TID ACHS once diet resume
- Polysinus disease
- Other findings as detailed
Hypovolemic Hypoosmolar No meds for now

Hyponatremia prob Hypovolemic Hypoosmolar Hyponatremia
Suboptimal Intake prob Suboptimal Intake
(-) weakness No active management
(-) dizziness
Asymptomatic Bacteriuria No meds for now Asymptomatic Bacteriuria

(-) dysuria No active management
(-) fever
(-) hypogastric pain Gyne Wise
No immediate gynecologic intervention
Gyne wise No meds for now warranted at this time
(-) profuse vaginal bleeding > For TVS UTZ as OPD basis
(-) severe hypogastric pain > For ffup at OB OPD on June 27, 2024 if still
amenable for OR
G8P8(8008) > Maximize medical management
Menopause x 23 years > Daily body and perineal hygiene
(since 54 years old) > Respectfully signing out of this case
> Refer back if warranted
Soft flabby abdomen, non-
tender
IE:
POP-Q:
Aa +3
Ba +9
C +5
gh 4cm
pb 3cm
tvl 6cm
Ap +3
Bp +6
D 9cm
LR DR
OB Ward
OB 1 G1P1 (1001) Pregnancy uterine BP 100/60 DAT CBC with PC DMPA
GOMEZ, ALYANNA ADRIANNE Delivered term cephalic HR 84 PNSS 1L x KVO while on BT Date Hgb Hct WBC S L M E Plt EINC
VILLANUEVA Live baby boy RR 20
06/10 9.7 L 0.29 L 25.2 H 90 5 5 - 404
21 AS 9,9 BW 2.97 kg BL 53 cm MI T 37.4
YC 39 weeks AGA 06/09 11.9 0.35 9.7 60 30 8 2 347
Blood transfusion of 1 unit pRBC I: 2050 A+/NR
06/09/24 for Anemia moderate secondary O: 1000 Urinalysis
3913998 to acute blood loss Date Sugar Protein WBC RBC Epithelial Bacteria Leukocyte
Dr Odevilas/ Tungcul Go/Roque Anemia moderate secondary s/p 1u pRBC 06/09 Neg Neg 6.2 3.9 11.0 12.3 Neg Anemia moderate secondary to
Reyes(TL)/Gauiran By Normal Spontaneous to acute blood loss Diphenhydramine 1amp TIM Ferritin (6/9/24 OSMAK): 25.38 acute blood loss
Tugado/Alzaga Delivery; Right Mediolateral (-) pallor 30mins prior to BT -given For anemia correction
Episiotomy with repair under (-) dizziness For repeat CBC of 6 hours post BT
EBL 1600 local anesthesia (06/10/24) (-) generalized body weakness of 1u PRBC (0800H)
pink palpebral conjunctiva
G1P1 (1001)
s/p NSD Day 1
Anemia moderate secondary to OB wise Cefuroxime 500mg tab 1 tab OB wise
acute blood loss No profuse vaginal bleeding every 12 hours x 7 days For anemia correction
No severe hypogastric pain Mefenamic acid 500mg/tab 1 Continue present management
Uterus well contracted tab every 8 hours for pain
Ferrous Sulfate 325mg tab 1
tab 2x a day
OB 9 G1P1 (1001) Pregnancy Uterine BPR 110-120/80 DASH CBC IUD

BALADIA, CRISCHELLE LAVA Delivered term cephalic BP 120/80 MgSO4 drip (completed Date Hgb Hct WBC S L M E Plt NICU well for
16 Live baby boy PR 93 06/09 12nn) 06/08 11.4 0.33 14.2 87 11 2 1 271 maternal risk
YC AS 7,9 BW 2.63 kg, BL 52 cm, MI RR 20 06/08 13.5 0.39 12.7 23 7 6 0 325 factor –
40 weeks, AGA T 36.7 B+/NR preeclampsia
165325 Preeclampsia with severe Urinalysis A 0, 1
06/08/24 features I: 8225 Date Sugar Protein WBC RBC Epithelial Bacteria P 2, 2
Dr. Bautista/ Tungcul/ r/o Hypertensive Retinopathy O: 4100 06/08 NEG NEG 0.6 0.5 10.8 6.5 G 1, 2
Gavino(TL)/ Gallano, Posadas/ Gestational diabetes mellitus, Coagulation Test A 1, 2
Tiongson diet controlled Last BP elevation: Date PT % Act INR APTT R 2, 2
Bronchial asthma not in acute 06/08 0638H160/110
06/08 11.4 105.9 1.01 26.7
0919H/1037H exacerbation, moderate, poorly (triage)-> 200/120 -> H5, Gestational diabetes mellitus,
800cc controlled MgSO4 4g LD -> 140/70 -> 75g OGTT (3/22/24)@ 27 weeks AOG diet controlled
Teenage pregnancy 160/100 -> H10 (0713H) FBS 92.34 H For CBG monitoring and control
1st hr 104.4 For CBG TID ACHS
By Emergency LTCS I under CLEA Gestational diabetes No medications for now 2nd hr 113.4 For 75g OGTT 4-12 weeks post op
for Impending Eclampsia with mellitus, diet controlled Chemistry:
IUD insertion (June 8, 2024) (-) polyphagia Date BUN Crea BUA Na K Cl LDH AST ALT Preeclampsia with severe
(-) polydipsia 06/08 2.23 47.95 300.8 135.4 3.92 103.58 278.22 13.28 7.73 features
G1P1 (1001) s/p E LTCS I under (-) polyuria For BP monitoring and control
CBG monitoring
CLEA Day 3 See CBG table TSR 24 hour urine CHON (Osmak)
Date 0500H 1100H 1700H 2100H
Preeclampsia with severe
features Preeclampsia with severe Nifedipine 30mg/tab 1 tablet 06/10 97 81 96 106 Ophtha Notes (6/9/24)
Gestational diabetes mellitus, features once a day 06/09 98 89 120 116 Seen and examined
diet controlled (-) headache MgSO4 4g SIVP as LD-given 06/08 83 89 90 96 Noted written clearance for
Bronchial asthma not in acute (-) dizziness Imaging dilatation from main service
exacerbation, moderate, (-) blurring of vision CXR(6/8/24 OSMAK) There are no active parenchymal opacities in both lungs. DFE done
controlled (-) Vomiting Pulmonary vascular markings are within normal limits. No management warranted
Teenage pregnancy The heart is magnified. ophtha-wise for now
Signing out of service
Both hemidiaphragms and costophrenic angles are intact.
Refer back once with new
Bony thorax is unremarkable. ophthalmologic concerns
Impression: Will update CIC
Magnified heart
Bronchial asthma not in acute
exacerbation, moderate,
controlled
Pedia Notes (06/10/24)
Patient seen and examined
Diet c/o main service
Maintain on heplock
Bronchial asthma not in Shift Hydrocortisone to Diagnostics: none for now
acute exacerbation, Prednisone 20 mg/tab twice a Therapeutics:
moderate, poorly controlled day for 3 days 1. Salbutamol nebulization 1 neb
Clear breath sounds Shift Salbutamol nebulization every 6 hours
(-) DOB/SOB to salbutamol ipratropium 2. Hydrocortisone 100mg IV every
(-) fever bromide nebule every 6 hours 6 hours
(-) cough Budesonide rapinhaler 160 For observation for 24 hours as
mcg 1 puff twice a day for 3 per consultant in charge (Dr.
months Paningbatan)
Pedia Pulmo (6/8/24)

Rounds with Pediatrics
pulmonologist
Shift Hydrocortisone to
Prednisone 20 mg/tab twice a
day for 3 days
Shift Salbutamol nebulization to
salbutamol ipratropium bromide
OB Wise nebule every 6 hours
No hypogastric pain Budesonide rapinhaler 160 mcg 1
No profuse vaginal bleeding puff twice a day for 3 months
(+) flatus Mother updated on patient’s
(+) BM current status and plans of
Cefuroxime 500mg tab 1 tab management
every 12 hours x 7 days
Paracetamol + Tramadol tab 1 OB Wise
tab every 8 hours for pain For possible discharge today once
Ferrous Sulfate 325mg tab 1 cleared by all onboard services
tab 2x a day
OB 13 G2P1(1001) Pregnancy Uterine BPR 120/70-80 DASH Diet CBC NA
BOHOLST, PRINCESS SORIANO 28 1/7 weeks AOG by BP 120/80 MgSO4 drip completed Date Hgb Hct WBC S L M E Plt
30 ultrasound cephalic not in labor PR 87 (06/08) 06/07 12.2 0.35 13.0 72 19 8 1 277
NYC Chronic hypertension with RR 20 B+/NR
superimposed preeclampsia T 37.0 Urinalysis
3932157 Hypokalemia secondary to Date Sugar Protein WBC RBC Epithelial Bacteria
06/07/2024 preeclampsia, corrected I: 2100 06/07 NEG NEG 2.5 5.9 47.7 226.6 H
Dr.Bautista/ Tungcul/ Gestational diabetes mellitus, O: 1900 Coagulation Test
Gavino(TL)/ Gallano, Posadas/ diet controlled
Date PT % Act INR APTT
Tiongson Bronchial Asthma not in acute Last BP elevation:
exacerbation 06/08 170/100 0046H  06/07 11.2 107.7 0.99 27.0
Obese I Hydralazine 5mg TIV; MgSO4 Ferritin (06/07, OsMak): 88.94
4g  140/70 HbA1c (06/07) 5.11%
Previous LTCS I for NRFS, - 75g OGTT (04/17, Olympus)@ 18 weeks AOG Chronic hypertension with
severe preeclampsia (2021, Chronic hypertension with Methyldopa 250mg/tab, 1 tab FBS 68.83 superimposed preeclampsia
RMC) superimposed preeclampsia 2x a day 1st hr 136.58 For BP monitoring and control
(-) headache Aspirin 80mg/tab 1 tab once 2nd hr 160.18 H
(-) dizziness a day Urine K (06/09 GA): 20.1 L
(-) blurring of vision Standby Hydralazine 5mg Chemistry:
(-) Vomiting then 10mg thereafter (max of Date BUN Crea BUA Na K Cl Mg LDH AST ALT Hypokalemia probably
25mg) if with BP of 3.86 secondary to preeclampsia,
06/10
>/=160/110 corrected
06/09 3.26 L 0.72 No active management
06/08 3.04 L
Hypokalemia probably KCl 750mg/tab 2 tablet x PO 06/07 1.5 L 41.50 L 268.8 138.4 3.16 L 104.24 238.4 15.72 14.6 IM Nephro (06/10/24)
secondary to preeclampsia, every 4 hours x 6 doses- Noted plans for discharge, no
Imaging
corrected completed objection for discharge
(-) Body weakness KCl 750mg/tab 2 tablet x PO Modified BPS UTZ (06/10, SLIUP Cephalic 148 bpm AHL gr 1 AFI 10.5 cm SDP 3.9 cm 8/8
(-) leg pain every 4 hours x 6 doses Osmak) Gestational diabetes mellitus,
- completed BPS UTZ (06/06/ 24) SLIUP cephalic 27w2d 144bpm 1102g Afi 18.77 SDP 6.06 AHL grade I 8/8 diet controlled
CAS (5/18/24; 5th lab ) SLIUPBreech 24w2d 151 bpm SDP 5.9 cm 712 g AH: gr 1 no previa, No gross fetal anomy seen For 7 point CBG monitoring
CBG monitoring Strict fetal kick monitoring
Date 0500H 0800H 1100H 1400H 1700H 2000H 2100H
06/10 74 82 81 89 79 80 79 IM Endo (06/10/24)
06/09 108 H 98 95 H 132 H 84 80 Noted CBG trends, noted diet
06/08 121 H 113 103 H 126 H 94 95 94 good appetite
Insulin Regular sliding scale 06/07 - - - - - 111 118 Advised 7 pt CBG monitoring
Gestational diabetes 110-150: 2u Tracing For strict DM diet
mellitus, diet controlled 151-200: 4u No objections for discharge
Date Interpretation BFHT Variability Acceleration Deceleration Contraction
(-) polyphagia 201-250: 6u Respectfully signing out
(-) polydipsia 251-300: 8u 06/11 AM Reactive 150-155 Moderate (+) (-) No contraction
(-) polyuria >300: 10u 06/10 PM Reactive 155-160 Moderate (+) (-) No contraction Bronchial Asthma Not in acute
See CBG table 06/10 AM Reactive 140-145 Moderate (+) (-) No contraction exacerbation
No active management
06/09 PM Reactive 155-160 Moderate (+) (-) No contraction
Bronchial Asthma Not in None for now 06/09 AM Reactive 145-150 Moderate (+) (-) No contraction OB Wise
acute exacerbation 06/08 PM Reactive 140-145 Moderate (+) (-) No contraction For discharge today if with no BP
(-) dyspnea 06/08 AM Reactive 140-145 Moderate (+) (-) No contraction elevations
(-) wheezes For BP control and monitoring,
(-) fever Monitor vsq4, FHT 4 and record
(-) cough For NST BID
Fetal kick monitoring q shift
OB Wise Multivitamins 1 tab once a Daily body and perineal hygiene
Good fetal movement day PROD informed (Dr. Almario)
(-) watery vaginal discharge Ferrous Sulfate 325mg/tab, 1 WOF: headache, blurring of
(-) bloody vaginal discharge tab once a day vision, vomiting, severe
(-) perceived irregular uterine Calcium Carbonate 500mg hypogastric pain, profuse vaginal
contractions tab 1 tab 3x a day bleeding, dec. FHT, dec. fetal
Dexamethasone 6mg TIM movement
G2P1(1001) every 12 hours for 4 doses
LMP: October 15, 2023 (completed 06/09 0900H)
UTZ:
34w2d by LMP
28w1d AOG by UTZ
(AOG:04/12, 19w4d)
Globular abdomen
(+) previous CS infraumbilical
scar
FH: 26 cm
FHT: 140s
IE: cervix closed
OB 20 G5P1 (1031) Pregnancy Uterine BP 90/60 DAT with SAP CBC with PC -NA
PAULINO, CHERIZZE FACUNDO 25 1/7 weeks AOG cephalic in HRR 89-106 Isoxuprine drip:– Date Hgb Hct WBC S L M E Plt
36 threatened preterm labor HR 89 (manual) DISCONTINUED 6/8 2200H 9.5 6
YC Acute gastroenteritis with no RR 20 IVF2: PNSS 1L x 60cc/hr – 06/11 0.27 L 6.1 27 8 4 205
L 1
signs of dehydration, resolved T 36.6 HOLD
9.0 6 1
06/05/2024 Anemia moderate secondary to O2: 99% (+) O2 support 06/09 0.26 L 5.3 17 2 135 L
L 7 4
105026 probably infection
8.5 8
Dr. Irabon, Castro/Tungcul/ Phlebitis I: 2500 06/08 0.24 L 6.2 8 6 144 L
L 6
Gavino, Reyes (TL) /Posadas, Multiple electrolyte imbalance O: 2300
9.9 8
Tugado/Tiongson, Jasarino (Hypokalemia, Hyponatremia) 06/07 0.28 L 9.4 11 5 1 147 L
L 3
secondary to poor intake, Pre-pregnancy weight: 62 kg
corrected Ht: 160cm 8
06/05 11.6 0.33 14.4 11 6 1 231
Bacterial vaginosis, ongoing BMI: 24.2 (overweight) 2
treatment O+/NR
Poor OB History – Recurrent Last febrile episode: Urinalysis
Pregnancy Loss 06/09 0000H Temp of 38.4  Date Sugar Protein WBC RBC Epithelial Bacteria
Mixed Hemorrhoids Paracetamol 600mg TIV  06/07 NEG NEG 0.3 0.2 4.7 3.3
Phlebitis 36.8 06/05 Neg Trace 2.2 0.8 37.8 38.8
Low lying placenta Chemistry:
Pleural effusion (minimal, left) Acute gastroenteritis with no Date BUN Crea Na K Cl Mg AST ALT
Elderly gravid signs of dehydration, 3.58 0.71 Acute gastroenteritis with no
06/10
Overweight resolved signs of dehydration, resolved
(-) epigastric pain ORS volume per volume 06/09 135.49 3.27 L 0.76 Discontinue IVF
Previous LTCS I for unrecalled (-) nausea replacement-Discontinued 06/08 2.34 49.26 133.47 L 3.28 L - 29.06 16.49
indication (2015, PGH) (-) vomiting (06/09) 06/05 136.00 4.28 101.12
(-) recurrence of loose stools Ranitidine 150 mg/tab 1 tab
Coagulation studies
(-) dry lips every 8 hours as needed for
(-) sunken eyeballs epigastric pain- Discontinued Date PT % Activity INR APTT
Last episode of vomiting (06/09) 06/08 13.1 92.7 1.17 34.5
06/04 1800H Troponin I 6/6: 0.16ng/mL
Last episode of loose stools Reticulocyte count 6/8: 3.3% (H)
06/05 0130H Ferritin 06/05 172.20H
Last BM: 06/09 75g OGTT (05/31, Makatilife) at 23 weeks
FBS 88 Multiple electrolyte imbalance
Multiple electrolyte KCl 750mg/tab 2 tablets every 1st hr 145 (Hypokalemia, Hyponatremia)
imbalance (Hypokalemia, 4 hours for 4 cycles 2nd hr 123 secondary to poor intake,
Hyponatremia) secondary to - completed Vaginal GS/KOH 06/05 Negative; SMEAR SHOWS PREDOMINANCE OF GRAM NEGATIVE COCCOBALLI WITH FEW LEUKOCYTES AND MANY EPITHELIAL CELLS. corrected
poor intake, corrected KCl 750mg/tab 2 tablets every Initial Urine CS (06/06, health): No growth after 24 hours of incubation No active management
(-) weakness 4 hours for 6 cycles – 12L ECG (6/6: sinus tachycardia (PR 115)
(-) vomiting/diarrhea completed Thyroid function test (06/06, OsMak) IM Nephro (06/10)
KCl 750 mg/tab 2 tabs now TSH 2.0 Noted labs
then 1 tab every 4 hours for 4 FT3 0.69 L KCl 750 mg/tab 2 tabs now then 1
doses – completed FT4 0.70 tab every 4 hours for 4 doses
Fecalysis then repeat K and Mg
Nephro-wise no objection if for
Date Consistency WBC RBC Others
discharge
Anemia moderate secondary None for now 06/04 Watery 0-1 0-1 NO INTESTINAL PARASITE SEEN Noted K correction c/o main
to probably infection Dengue Serology (06/09, Life) service
(-) pallor NS1 Negative
(-) PPC IgG Negative Anemia moderate secondary to
(-) DOB/ SOB IgM Negative probably infection
Continue present medications
Imaging and management
Chest xray (6/8/24 Previous study dated April 19, 2021 was review.
Bacterial vaginosis Metronidazole 500mg/tab 1 OSMAK) The lungs are hypoaerated with bronchovascular crowding.
(-) foul smelling discharge tab every 12 hours for 7 days There is minimal haziness in the left lower lung. Bacterial vaginosis
(-) whitish vaginal discharge (D6) The heart is magnified. For completion of antibiotics
The left costophrenic sulcus is indistinct. Daily perineal hygiene
Mixed Hemorrhoids Both hemidiaphragms and the right costophrenic angle are intact.
(+) tender non reducible mass None for now Bony thorax is unremarkable. Mixed Hemorrhoids
at 12’o clock position IMPRESSION: No active management
(-) anal itching Minimal haziness in the left lower lung, may be due to vascular crowding. Please correlate clinically
(-) rectal bleeding Minimal pleural effusion versus thickening, left SURGERY ER notes 4/6/2023
Case referred to Dr Atazan
Pelvic with Cervical The cervix measures 4.7 x 2.8 x 2.8 cm (CcxAPxW). Y-shaped funneling of the cervix is noted, with funnel length of 3.4 cm, No immediate surgical
Length (06/05/2024) funnel width of 1 cm, and functional cervical length of 1.3 cm (percentage funneling = 70%). intervention warranted at time of
SLIUP, cephalic, 24 3/7 weeks, 727 grams, 147 beats/minute, Placenta maturity is grade 0 located at the anterior lower exam
portion of the uterus, 1.5 cm away from the internal os, DVP 2.3cm Avoid straining, lifting heavy
IMPRESSION: object and prolonged
Cervical funneling, as detailed standing/walking
Single live intrauterine pregnancy, cephalic in presentation compatible with 24 weeks and 3 days gestational age by fetal For hot sitz bath at home TID 10-
biometry with good cardiac and somatic activities. 15mins
Normohydramnios If ok with OB (if w/o
Grade 0 anterior low-lying placenta contraindication), to start
EFW: 727 grams Hisperidin-Diosmin 500mg tab 1
EDD by ultrasound: September 22, 2024 tab TID x 5 days – not started by
CAS, Makati Life 05/29 SLIUP, Breech, 23w2d, 149 bpm, AHL gr 1, SDP 5.57 cm, 593 g, No gross fetal anomaly main service
No objection if for discharge
Stool charting:
Phlebitis discontinued Phlebitis
(-) warm to touch and Paracetamol 300mg TIV every 06/05 0130H 1 loose bowel movement IM IDS (06/10)
tenderness on IV access, left 6 hours for temp >37.8 C PRN Patient seen and examined
Will attribute febrile episode to
phlebitis
Will not treat as pneumonia since
with no cough, colds with clear
breath sounds on auscultation
Continue monitoring CBC for now
Pleural effusion (minimal, Ceftriaxone 2 g TIV OD (D1) Pleural effusion (minimal, left)
left) IM-Pulmo notes (06/09/24)
(+) fine crackles, left lower Dr Dizon updated
lung field CXR finding not infectious in
(-) DOB/SOB origin
(-) cough Agree to shift to heplock for now
(-) orthopnea No active management
Signing out
OB wise Dexamethasone 6 mg TIM
Good fetal movement every 12 hours for 4 doses – OB wise
(-) watery vaginal discharge completed: 6/6 2215) PLAN: For workup of infection
(-) bloody vaginal discharge Multivitamins 1 tab once a due to recurrent febrile episodes
(-) perceived irregular uterine day For possible pessary placement
contractions Multivitamins + AA tab, 1 tab once infection resolved
twice a day TSR daily CBC for today
G5P1 (1031) Ferrous Sulfate 325mg/tab, 1 Monitor vsq4, FHT q4
LMP: 12/17/23 tab once a day PROD informed (Dr. Abis)
AOG: Calcium carbonate 500 WOF: severe hypogastric pain,
25 1/7weeks by LMP mg/tab 1 tab 2x daily profuse vaginal bleeding, dec.
24 2/7 weeks by UTZ (3/20/24 Dydrogesterone 10mg/tab 1 FHT, regularly perceived
12w5d) tab every 8 hours for 7 days contractions
REVISE micronized
FH 23cm progesterone for OD to BID PERINATOLOGY NOTES (6/10/24)
FHT 130s per vagina until 36 weeks Referred back to Dr. Castro
IE: cervix closed Isoxsuprine 10mg /tab, 1 tab Noted CBC trends
3x daily for 7 days – HOLD Noted ongoing K correction
Please facilitate cervical length
monitoring- tentative sched
06/11/24 c/o OB sono
For canvassing of pessary c/o
patient – amenable
WOF: decreased fetal movement,
watery/bloody vaginal discharge,
recurrence of fever, vomiting,
perceived uterine contractions
Pending:
[ ] For confirmation of cervical
length; for amniotic fluid sludge
c/o OB Sonologist – on Tuesday
(June 11, 2024)
[ ] For canvassing of pessary c/o
patient – amenable
[ ] TSR urine culture c/o GA after
5 days (done 6/6)
[ ] For APAS workup (still for LOA
approval)
HR 3 G2P1 (1001) Pregnancy Uterine BP: 120/80 DM diet with SAP CBC with PC N/A
GOYALA, MARITES ESPINAS 32 5/7 weeks AOG by HR: 96 Heplock Date Hgb Hct WBC S L M E Plt
26 ultrasound cephalic in RR: 20
06/03 12.2 0.36 9.0 74 17 6 3 215
YC threatened preterm labor T: 37.0
Gestational Diabetes Mellitus, O2: 98% A+/NR
06/03/24 diet controlled Urinalysis
3930475 CAP MR with MDRO I: 2103 Date Sugar Protein WBC RBC Epithelial Bacteria
Dr. Calo/ Tungcul, Go/ Gavino Bronchial asthma not in acute O: 2100 06/03 NEG NEG 1.0 0.1 11.6 4.6
(TL), Reyes/ Gallano, Gauiran/ Exacerbation, moderate, poorly 06/03 NEG NEG 6.2 H 18.6 H 64 H 321.7 H Gestational Diabetes Mellitus,
Kadappurath controlled Gestational Diabetes None for now Ferritin (06/03/24) 13.95 diet controlled
Bacterial Vaginosis, ongoing Mellitus, diet controlled HbA1c (06/03/24): 4.25% For CBG monitoring and control
treatment (-) polyphagia 75gOGTT (05/22/24) Megason at 30 weeks AOG For 7 point CBG monitoring
(-) polydipsia FBS 108.54 H For strict fetal kick monitoring
(-) polyuria 1sthr 150.3
See CBG table 2ndhr 113.22 CAP MR with MDRO
Vaginal Discharge GS (06/03/24): SMEAR SHOWS PREDOMINANCE OF GRAM POSITIVE LACTOBACILLI, MODERATE LEUKOCYTES, MODERATE EPITHELIAL CELLS AND Bronchial asthma not in acute
CAP MR with MDRO Ceftazidime 2g TIV every 12 OCCASIONAL GRAM NEGATIVE BACILLI Exacerbation, moderate, poorly
Bronchial asthma not in hours (D2+1) Vaginal KOH (06/03/24): NEGATIVE controlled
acute exacerbation, Budesonide + Formoterol Procalcitonin (06/06): 0.06 Referred back to IM Pulmo/IDS
moderate, poorly controlled 160mcg/4.5mcg 2 puffs twice Imaging (Dr. Antonio)
(-)wheezes, a day Hemithorax (06/10/24) Findings:
(-) cough Radiograph study dated June 4, 2024 was reviewed. IM Pulmo (06/10)
(+) decrease breath sounds, There is hypoechoic hepatization involving the right lung with areas of punctate Patient seen and examined
right basal lobe hyperechogenicities representing static air bronchograms. Continue Ceftazidime for now
(-) DOB/ SOB There is no fluid collection appreciated in both hemithoraces. Facilitate hemithorax UTZ today
(-) fever
(-) desaturations Impression: IM-IDS notes (06/09/24)
Consider right lower lung consolidation and/or atelectasis Noted with Dr Gozum
Bacterial Vaginosis, ongoing Metronidazole 500mg tab 1 BPS UTZ (06/10/24) SLIUP cephalic 32w3d 154 bpm 1989 g AHL gr 2 AFI 10.2 cm SDP 4 cm 8/8 Continue antibiotics for now
treatment tab every 12 hours x 7 days Chest xray (06/04/24) Unchanged consolidation Pneumonia with atelectatic component, right lower lung Facilitate pending labs
(-) foul smelling vaginal (D6) BPS UTZ (06/03/24) SLIUP, cephalic, 31w1d, 146bpm, 1771g, AFI: 11.75 SDP: 4cm, AHL grade 2, 8/8 refer
discharge Pelvic UTZ (05/14/24, Osmak) SLIUP, Breech, AOG 27w3d, EFW 1055g, FHR 148bpm, SDP 5.03cm, Placenta AHL gr I
(-) fever Tracing Pulmo Notes (06/08/24)
(-) hypogastric pain Updated Dr. Estrella (Pulmo)
Resume Ceftazidime 2g TIV every
OB Wise Multivitamins 500mg/capsule 06/11 AM Reactive 145-150 bpm Moderate (+) (-) No contraction 12 hours
Good fetal movement 1 cap once daily 06/10 PM Reactive 140-145 bpm Moderate (+) (-) No contraction Continue Budesonide +
(-) bloody vaginal discharge Multivitamins + Amino acid 1 06/10 AM Reactive 140-145 bpm Moderate (+) (-) No contraction Formoterol 160/4.5 mcg 2 puffs
(-) whitish vaginal discharge cap once daily 2x a day
06/09 PM Reactive 155-160 bpm Moderate (+) (-) No contraction
(-) perceived uterine Ferrous sulfate 325mg/cap 1 Facilitate hemithorax UTZ
contractions cap once daily 06/09 AM Moderate Suggest referral to IDS for
Reactive 140-145 bpm (+) (-) No contraction
Calcium tab 1 tab 2x daily post-terb clearance
G2P1 (1001) Isoxsuprine 10mg tab every 8 06/09 AM CAT 1 145-150bpm Moderate (+) (-) 2 moderate contractions
LMP: Nov 6, 2023 hrs x 7 days 06/08 PM Reactive 140-145 bpm Moderate (+) (-) No contraction Bacterial Vaginosis, ongoing
AOG: 30 6/7 weeks Dexamethasone - completed treatment
06/08 AM Reactive 140-145 bpm Moderate (+) (-) No contraction
AOG: 32 5/7 weeks (02/20: 16 (06/08/24; 0800H) Completion of antibiotics
6/7 weeks) 06/07 PM Reactive 140-145 bpm Moderate (+) (-) No contraction
06/07 AM Reactive 140-145 bpm Moderate (+) (-) No contraction OB Wise
FH 27cm 06/06 PM Reactive 150-155 bpm Moderate (+) (-) No contraction For control of bronchial asthma,
FHT 140s bpm treatment of CAP MR
06/06 AM Reactive 140-145 bpm Moderate (+) (-) No contraction
IE: parous introitus, vagina For IE once with indication
admits 2 fingers with ease, 06/05 PM Reactive 145-150 bpm Moderate (+) (-) No contraction Monitor vsq4, I & O qshift
cervix closed 06/05 AM Reactive 140-145 bpm Moderate (+) (-) No contraction NST BID, FHTq4 and fetal kick
06/04 PM Reactive 140-145 bpm Moderate (+) (-) No contraction monitoring
PROD informed Dr. Carandang
06/04 AM Reactive 145 bpm Moderate (+) (-) No contraction
(with 1 incubator available c/o
06/03 PM Reactive 155 bpm Moderate (+) (-) No contraction Dr. Carandang)
CBG monitoring
Date 0500H 0800H 1100 1400H 1700H 2000H 2100H Pending labs
06/09 70 72 80 89 77 69 73 [/] Hemithorax ultrasound on
06/08 130 84 80 98 110 117 98 June 10, 10AM c/o Dr. Obsum
06/07 107 132 87 127 106 152 159 [/] BPS UTZ on June 10, 2024 (c/o
06/06 80 73 82 81 98 94 101 Dr. Capuchino)
06/05 82 78 127 122 92 95 92
06/04 74 82 89 102 118 98 116
06/03 - - - - 128 74 82
HR 4 G3P2 (2002) Pregnancy Uterine BPR 110-120/70-80 LSLF diet CBC/PC n/a
CABUENAS, JENELYN ABEÑON 28 3/7 weeks AOG by LMP BP 110/70 Heplock Date Hgb Hct WBC S L M E Plt
32 breech not in labor HR 91 06/10 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 36.7 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: 2901 05/08 11.1 0.32 11.1 67 25 7 1 269
Dr. Palomares, Castro/Tungcul, infection, high infectivity O: 1900
05/04 11.7 0.33 9.7 64 24 9 1 281
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 Chronic Hypertension
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 For BP monitoring and control
Vaginal Candidiasis, resolved (-) headache needed for chest pain B+/R
(-) dizziness Urinalysis Deep Vein Thrombosis
(-) chest pain Date Sugar Protein WBC RBC Epithelial Bacteria Well’s score 5
(-) DOB/SOB VTE score 1
05/11 Neg Neg 0-2 0-2 Mod Rare
(-) vomiting Anesthesiology notes (06/09)
05/03 neg neg 0.9 0.4 13.7 27.7 Referred last night at 6pm via
Deep Vein Thrombosis Enoxaparin 8000 units SC 2x a 04/29 Neg Neg 2.1 0.9 26.5 40.9 phone call by Dr Pesigan
Well’s score 5 day 04/24 Neg Neg 3.1 0.5 51.2 233.1 H No clinical referral sheet as of
VTE score 1 Chemistry: now, still awaiting
(+) swelling of the leg and Noted history and labs
Date BUN BUA Crea Na K T Ca Mg AST ALT Trop I FBS HBA1c
thigh, left Please secure 1u pRBC properly
(-) direct tenderness 06/10 2.43 43.76 133.62 L 3.90 12.20 15.45 typed and crossmatched and 1u
(-) warm to touch, left leg 46.22 134.97 L 4.05 0.80 pRBC as standby for possible OR
05/30 2.27
(-) red/discoloration on the use
affected leg 05/15 2.62 46.02 134.63L 3.9 0.73 Please secure second IV line on
(-) shortness of breathing 05/08 2.61 45.74 contralateral arm then heplock if
(-) pain on deep breathing for OR
(-) pain/tenderness on the 05/05 75.06 4.94 Please discontinue enoxaparin 24
affected leg when 04/29 2.76 50.52 131.9 L 3.93 2.34 0.68 hours prior to OR
standing/walking
04/20 2.25 325.07 46.27 10.58 12.59 0.37
(-) sensory loss Surgery (06/10/24)
(+) good lower extremity Coagulation studies Continue present management
pulses (posterior popliteal, Date PT % Activity INR APTT Noted plans for IVC filter creation
posterior tibial, dorsalis pedis 05/10 12.0 100.8 1.07 27.3 at about 36 weeks AOG at PGH
2+)
05/08 12.0 100.8 1.07 26.3
IM Vascular (06/10/2024)
04/20 11.7 103.3 1.04 24.9 L Patient seen and examined
D-dimer (03/01/24): >3000 (H) Continue Enoxaparin 8000 units
Hepatitis profile (04/05/24) SC 2x a day
HbsAg REACTIVE Continue application of
Anti-HAV REACTIVE compression stockings (12 hours
Chronic Active Hepatitis B No meds for now on, 12 hours off)
Anti-HAV IgM NONREACTIVE
infection, high infectivity
Hepatitis A infection Anti-HCV NONREACTIVE IM Cardio (05/30/2024)
(-) icteric sclerae/jaundice Anti-HBc IgG REACTIVE Continue Enoxaparin 8000 units
(-) abdominal pain Anti-HBc IgM NONREACTIVE subcutaneously 2x a day
known Hep B since 2011 Facilitate venous duplex scan- -
HbeAg REACTIVE
done
Anti-HBs NONREACTIVE still for 2D Echo as scheduled
Anti-Hbe NONREACTIVE For CBC BUN Crea Na K Mg-done
12L ECG
04/26 Normal sinus rhythm Chronic Active Hepatitis B
infection, high infectivity
04/23 Normal sinus rhythm
Hepatitis A infection
Vaginal GS/KOH 05/03/2024: Positive; For HBV DNA viral load c/o
Vaginal GS/KOH 05/03/2024 SMEAR SHOWS PREDOMINANCE OF GRAM POSITIVE LACTOBACILLI WITH MANY LEUKOCYTES, MANY EPITHELIAL CELLS AND outside institution -refused,
PRESENCE OF FUNGAL ELEMENTS waiver secured
Imaging
Pelvic UTZ c/o SLIUP, 25w2d, Breech, 127bpm,SDP: 5.69, 777g, Fundal Grade II placenta GASTRO 04/25/2024
t/c Anxiety disorder None for now OB Sono Impression: Known to service from previous
(-) difficulty of sleeping (06/03/24) *Estimated fetal weight is below the 10th percentile of the established gestational age, suggest serial growth monitoring. admission
(-) palpitation *Fetal face cannot be fully assessed due to unfavorable fetal position Still for HBV DNA
(-) DOB No medications for now
Venous duplex Vein diameter (cm): Left
(-) chest pain Contact precaution
Scan Greater saphenous vein (above knee): 0.22
05/11 0830H DOB (no No active gastro management,
(05/31/24 Greater saphenous vein (below knee): 0.19
triggering factors) Metronidazole + Miconazole respectfully signing out of this
OSMAK) Greater saphenous vein (ankle): 0.15
750/200mcg/tab, 1 tab once case
Lesser saphenous vein: 0.26
Vaginal Candidiasis, resolved a day before bedtime Refer back once with HBV DNA
Saphenofemoral junction: 1.31
(-) white frothy discharge (completed 05/13) result
The left common femoral vein, superficial femoral vein, deep femoral vein and popliteal veins are now partially compressible. The left
(-) perceived uterine Thank you
saphenofemoral junction and greater saphenous vein are now compressible with intraluminal medium level echoes. The left posterior tibial
contractions and peroneal veins are now compressible.
(-) foul smelling discharge t/c Anxiety disorder
No significant varicosities seen.
MHU (05/29)
The lesser saphenous vein again has thickened walls with calcifications.
Patient comfortable, no pain at
The previously noted cobblestoning along the subcutaneous region of the popliteal region extending to the ankle is no longer evident.
the moment
Impression
Dexamethasone 6mg TIM Continue management
- Interval regression of findings suggestive of venous thrombosis, as detailed above.
OB wise every TIM for 4 doses (1st - Unchanged thickened wall with calcifications, left lesser saphenous vein.
Good fetal movement dose given at 06/09 0100H; Vaginal Candidiasis, resolved
- Resolution of subcutaneous edema, popliteal down to the ankle region
(-) perceived uterine 2nd dose: 06/09 1300H No active management
contractions 3rd dose: 06/10 0100H CAS (05/13 SLIUP, 22w4d, breech, AHL grade I, 150bpm, SDP 2.89cm, 547g
(-) watery/bloody vaginal 4th dose: 06/10 1300H) OSMAK) The estimated fetal weight is below the 10th percentile of the established gestational age, suggest serial growth monitoring. OB wise
discharge Multivitamins + amino acid Limited congenital anomaly scan showed no gross congenital anomaly seen at the time of scan (Face not fully assessed due to unfavorable Definitive plan:
tab 1 tab 2x daily fetal position); Suggest re-evaluation of the fetal face. For readmission to PGH at 36
G3P2 (2002) Ferrous sulfate 325mg/tab 1 Chest xray No significant chest findings weeks for possible IVC filter
LMP: November 25, 2023 tab twice a day (05/11) insertion (for reassessment if still
AOG: Calcium 500mg/tab 1 tab 2x a 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 warranted)
28 3/7 weeks by LMP day (04/24) For vacuum delivery, but for
27 5/7 weeks (02/14; 10w6d) Nifedipine 10mg/tab, TID for delivery anytime if with
Pelvic UTZ SLIUP cephalic 17w1d 174 g 147 bpm SDP 3.8 cm AHL gr 1
48 hours – completed fetomaternal indication such as
(04/01)
FH 26cm Isoxuprine 10mg/tab, 1 tab recurrent severe hypertension,
FHT: 120 bpm every 8 hours x7 days- done Chest xray no active parenchymal opacities in both lungs. progressive renal insufficiency,
IE: cervix closed, uterus (04/04) Pulmonary vascular markings are within normal limits. persistent thrombocytopenia,
enlarged to AOG The heart is not enlarged. pulmonary edema, eclampsia,
Both hemidiaphragms and costophrenic angles are intact. suspected abruptio placenta,
Bony thorax is unremarkable. severe fetal growth restriction,
Impression: No significant chest findings BPS 4/10 or less on at least 2
Venous duplex The left common femoral and proximal superficial femoral, visualized deep femoral, as well as the popliteal, posterior tibial and peroneal occasional 6 hours apart,
Scan veins are non-compressible now with intraluminal hyperechoic component and with absent color flow upon Doppler interrogation. The left recurrent variable or late
(03/23/24) saphenofemoral junction and proximal greater saphenous vein are now also non-compressible and with intraluminal hyperechoic foci and decelerations
with absent color Doppler flow. For BPS + doppler velocimetry
The rest of the greater saphenous vein is non-dilated and compressible. No significant varicosities seen. (Dr. Gauiran informed)
The lesser saphenous vein again has thickened walls with calcifications. For dexamethasone completion
There is further decrease in the degree of cobblestoning of the subcutaneous region of the popliteal region down to the ankle. For NST BID
Impression: Monitor vsq4, FHTq6 and record
- Interval evolution of findings suggestive of venous thrombosis, as detailed above. Apply compression stockings at
- Thickened wall with calcifications, left lesser saphenous vein. all times
- Regression of subcutaneous edema, popliteal down to the ankle region PROD informed (Dr. Calacday)
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 AROD informed (Dr. Concepcion)
(03/16/2024) 6.03 cm, consider myoma uteri WOF: severe hypogastric pain,
profuse vaginal bleeding, chest
Venous duplex The left common femoral and entire superficial femoral and visualized deep femoral veins, as well as the popliteal, posterior tibial and
pain, DOB/SOB, decreased fetal
Scan peroneal veins are non-compressible with absent color flow upon Doppler interrogation. The proximal segment of the left saphenous vein is
movement
(03/09/24) partially to non-compressible with thickened walls. Wall calcifications are seen in the lesser saphenous veins.
Please measure calf
There is also no noted vascular flow in the visualized left external iliac vein.
circumference, thigh
The greater saphenous vein is non-dilated and compressible. No significant varicosities seen. No significant venous blood flow reflux seen
circumference daily and record
on maneuvers.
There are unenlarged left inguinal lymph nodes with intact fatty hila.
Perinatology notes (06/10/24)
There is cobble stoning of the subcutaneous region of the proximal left thigh down to the distal leg.
Referred back to Dr. Castro
- Consider venous-occlusive disease or thrombosis, left common femoral, entire superficial femoral, visualized deep femoral, popliteal,
Still for BPS + Doppler
posterior tibial, peroneal and proximal lesser saphenous veins.
velocimetry
- Consider venous-occlusive disease or thrombosis, left external iliac vein.
Still awaiting surgery notes for
- Wall calcifications, left lesser saphenous vein.
reassessment
- Subcutaneous edema, proximal left thigh down to the distal leg
Noted ongoing Dexamethasone
- Unenlarged left inguinal lymph nodes
completion
TVS UTZ Uterus is anteverted and enlarged measuring 9.63 x 8.79 x 1.67 cm. Myometrial echopattern is homogeneous. A hypoechoic focus Continue present management,
(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) medications and monitoring
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 WOF: decreased fetal movement,
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 watery/bloody vaginal discharge,
cardiac activity noted at 171 beats/min. nausea, vomiting, headache, BOV
There is no subchorionic hemorrhage.
Cervix is long and closed measuring 4.37 x 4.55 x 3.65 cm with no demonstrable lesions. Pending labs:
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 [ ] For 2D echo at Makatilife on
vasculature measuring 1.27 x 1.14 x 1.51 cm. July 9,2024
The left ovary is obscured by bowel gas. [ x] HBV DNA-refused
No definite lesion in both adnexa. [ ] To retrieve duplex scan result
No definite evidence of fluid seen in the posterior cul-de-sac. done at PGH
IMPRESSION: [ ] Ideally for 75g OGTT at 24-28
Single live intrauterine pregnancy compatible with 10 weeks and 6 days age of gestation by crown-rump length. weeks - GA not amenable since
EDD: September 5, 2024 the patient is admitted
Unremarkable sonogram of the cervix. [ ] For pelvic ultrasound after 2
Normal-sized right ovary with physiologic cyst. Non-visualized left ovary weeks (6/17/24) – still to
No evident posterior cul-de-sac fluid. coordinate
[ ] For BPS + doppler velocimetry
Tracing (Dr. Gauiran informed)
*Still processing aid from other
06/11 AM Reactive 145-150 Moderate (+) (-) No contractions government institution for
06/10 PM Reactive 140-145 Moderate (+) (-) No contractions guarantee letter
06/10 AM Reactive 145-150 Moderate (+) (-) No contractions DSWD P5000
PCSO-rejected
06/09 PM Reactive 135-140 Moderate (+) (-) No contractions
Office of VP- awaiting
06/09 AM Reactive 140-145 Moderate (+) (-) No contractions Bong Go- not available,
06/09 PM Reactive 145-150 Moderate (+) (-) No contractions Enoxaparin
LEFT Mid-Calf Mid-Thigh

06/10 39 60
06/09 39 60
06/08 39 61
06/07 40 60
06/06 39 60
06/05 40 60
06/04 39 63
06/03 38 63
06/02 38 63
06/01 38 63
05/31 39 63
05/30 39 63
05/29 36 63
05/28 37 62
05/27 38 63
05/26 39 62
05/25 39 63
05/24 38 63
05/23 39 63
05/22 38 62
05/21 38 62
05/20 37 61
GYNE WARD
PATIENT INFORMATION DIAGNOSIS SUBJECTIVE/OBJECTIVE THERAPEUTICS LABORATORIES PLAN/NOTES
Gyne 1 Nulligravid BP 90/60 NPO CBC with PC

ESCIETE, MARIAFE GARA Ovarian new growth, right PR 72 IVF: D5LR 1L x 30gtts/min *Endorsed patient by Dr. Binay
Date Hgb Hct WBC S L M E Plt
52 probably benign RR 20 *with reserved blood products
NYC Ovarian Torsion, right T 36.6 06/09 10.7 L 0.31 L 5.4 57 33 8 2 214 c/o Dr. Binay -2 crossmatched
Myoma Uteri c/o Maam Me-ann
06/04/24 I: 2580 06/08 11.4 0.34 5.9 55 36 7 2 228 *secured waiver that specimen
3931955 s/p Total Abdominal O: 1810 is for send out and is well
06/07 11.7 0.34 6.1 58 32 8 2 212
Dr. Palomares/Tungcul, Hysterectomy, Bilateral explained to patient and
Go*/Reyes (TL)/Gallano, salpingoophorectomy under HT: 157cm 06/05 11.3 0.33 6.7 59 33 7 1 199 relative
Gauiran/Kadappurath CLEA (06/10/2024) WT: 45kg
BMI: 18.3 (underweight) 06/04 12.6 0.37 9.7 70 23 7 0 258
1308H/ 1528H O+/NR
EBL 300 cc Anemia mild probably s/p BT of 1u pRBC Urinalysis
secondary to suboptimal Diphenhydramine 1am TIM prior Date Sugar Protein WBC RBC Epithelial Bacteria
intake to BT- given Anemia mild probably
06/05 NEG NEG 0.6 0.4 41.6 1.5
(-) pallor secondary to suboptimal intak
06/04 NEG Trace 8.0 H 0.8 55.5 H 61.7 H
(-) dizziness s/p BT of 1u pRBC
Chemistry
(-) generalized body no active management for now
weakness Date BUA HbA1c AST ALT Na K Crea BUN
Pink palpebral conjunctiva 06/09 138.88 Asymptomatic bacteriuria
06/09 For completion of antibiotic
06/08 139.27
Asymptomatic bacteriuria Standby Paracetamol 06/05 247.46 5.07 23.08 19.34 Gyne Wise
(-) dysuria 500mg/tab 1 tab every 4 hours 06/04 133.30 L 3.86 93.84 H 4.09 For repeat CBC 24 hours postop
(-) hematuria as needed for temp >37.8c Coagulation studies For diet progression 24 hours
(-) fever Date PT % Activity INR APTT postop c/o RIC
06/05 11.2 107.7 0.99 37.5
Pregnancy Test (06/04/24): NEGATIVE Surgery Notes at ER level
COVID 19 RAT (06/04/24): NEGATIVE (06/04/24)
12L ECG (06/04/24): sinus bradycardia Thank you for this referral
Tumor Markers (06/05/2024): patient seen and examined
Gyne Wise Doxycycline 100 mg every 12 Ca-125: 15.43 History and PE reviewed
(-) Severe hypogastric pain hours PO for 14 days (D0+1) Ca-19-9: 9.92 will refer to service consultant
(-) Profuse vaginal bleeding Discontinued Papsmear (06/06): MILD TO MODERATE INFLAMMATION CONSISTENT WIH ACUTE CERVICOVAGINITIS Diet and IVF as ordered
(-) Flatus Metronidazole 500 mg/IV every Vaginal Discharge KOH 06/04/24) NEGATIVE no immediate surgical
(-) BM 12 hrs – Discontinued Vaginal Discharge SGS (06/04/24) SMEAR SHOWS OCCASIONAL GRAM POSITIVE LACTOBACILLI WITH OCCASIONAL LEUKOCYTES AND EPITHELIAL CELLS intervention warranted at time
Metoclopramide 10mg/TIV Imaging of exam
every 8 hours as needed for TVS UTZ 06/04/2024 c/o OB Sono Uterus 5.53x4.76x7.2cm For serial abdominal exam
nausea and vomiting M1- Fundal, intramural with subserous component measuring 5.8 x 4.3 x 5.2 cm (>50% intramural) FIGO 5 will ff up patient
M2- Anterior, intramural measuring 1.8 x 1.6 x 1.9 FIGO 4
M3- Posterior, intramural measuring 1.7 x 1.3 x 1.8 cm FIGO 4 MRA (06/06)
ES 0.15cm > Thank you for this referral
Cervix 2.9x1.9x2.1cm > Referred to Dr Diaz-Garcia
Right Ovary not visualized MEDICAL RISK ASSESSMENT:
Left Ovary: with unilocular, cystic, no solid component, no acoustic shadowing, no color measuring 8.7 x 6.9 x 7.4 cm; probably benign A. Clinical Predictor: Low risk
by IOTA simple rules. (no known comorbidities)
Impression: B. Functional Predictor: Low
Myoma Uteri risk
Thin Endometrium C. Surgical Predictor:
Ovarian New Growth, left ovary, probably benign as described Intermediate risk (For
Right ovary not visualized. Intraabdominal)
Xray – CHEST/ABDOMEN Chest: Over-all Medical Risk
(6/04/24) There are no active parenchymal opacities in both lungs. Assessment:
Pulmonary vascular markings are within normal limits. Patient has Intermediate risk to
The heart is not enlarged. develop cardiopulmonary
Both hemidiaphragms and costophrenic angles are intact. complications.
Bony thorax is unremarkable.
Impression: Anesthesia Notes (06/07/24)
No significant chest findings May discontinue O2
Follow-up study (6-4-2024 0655H) shows no significant change since the prior study. May transfer back to ward
--------------------
Abdomen:
The bowel gas pattern is within normal limits.
No differential air fluid levels noted.
Rectal gas is seen.
There are no abnormal intra-abdominal calcifications.
The soft tissues do not appear unusual.
The visualized bones are intact.
Impression:
No localizing signs in the abdomen
TVS UTZ Clinical data: Right lower quadrant pain; with plain whole abdominal CT done outside (initial reading: non-dilated appendix)
(06/04/24) Findings:
Uterus is anteverted and normal in size measuring 4.2 x 4.9 x 5.9 cm (volume of 63.1 ml).
Myometrial echopattern is homogeneous.
A round hypoechoic subserosal focus is seen in the posterior lower uterine segment measuring 2.6 x 2.7 x 3.1 cm
Endometrial lining is not thickened measuring 0.4 cm.
The cervix is normal in size measuring 2 x 2 x 2.7 cm.
The right ovary is not visualized.
The left ovary is normal in size measuring 1.8 x 3.3 x 1.2 cm (volume of 2.6 ml).
There is a large dilated tortuous tubular structure in the mid pelvic region, anterior to the uterus, which appears to arise from the right
adnexal region. Its widest diameter measures 5.6 cm.
Minimal pelvic fluid is noted.
Impression:
- Large dilated tortuous tubular structure in the mid pelvic region, probably from the right adnexa; consider hydrosalpinx. Suggest
clinical correlation.
- Unremarkable sonogram of the cervix.
- Minimal pelvic ascites.
- Normal-sized anteverted uterus with non-thickened endometrium and subserosal myoma (FIGO 5)
- Normal-sized left ovary.
- Non-visualized right ovary.
PLAIN WHOLE ABDOMINAL CT FINDINGS:
SCAN The liver is normal in size and attenuation with no definite mass noted. Intrahepatic ducts are not dilated.
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
hydronephrosis, lithiasis or mass seen. Visualized ureters are not dilated.
The small and large bowel loops are in a non-obstructive pattern. No evidence of bowel wall thickening noted. Fecal materials are seen
within the colon. The appendix is distinct and measures 0.5 cm. No evident periappendiceal strandings noted.
No enlarged retroperitoneal nodes seen.
The urinary bladder is distensible with no stones nor mass. The wall is not thickened.
The uterus measures 6.2 x 5.4 x 5.1 cm, is anteverted and is unremarkable. Both adnexae show no abnormal findings.
There is no evidence of ascites.
Minimal spur formation is seen along the anterolateral endplates of the lumbar spine.
Visualized lower lungs are unremarkable.
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.
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.
Gyne 2 G2P2 (2002) BP 90/60 Diet: 1350 (SF 30) with PF 1.5 CBC with PC
HILARIO, AILEEN MENDOZA Pelvoabdominal mass HR 94 Using regular diet divided into 3 Date Hgb Hct WBC S L M E Plt
44 probably uterine in origin, RR 20 meals and 2 snacks with the ff 06/08 s/p
NYC probably malignant T 36.5 (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 (resolved) CHO 160 650
06/08 8.4 L 0.26 L 13.5 H 82 7 10 1 460
05/29/2024 secondary from severe I: 2016 CHO 160 650
05/30
3931666 anemia probably secondary O: 1700 Fats 50 430
S/p BT of 11.1 0.34 22.7 H 86 7 6 1 393
Dr Calo/ Tungcul/Gavino(TL)/ to chronic blood loss Boost optimum 2 scoops
3u pRBC
De Guia Gauiran/Kadappurath Blood transfusion of 4 units Ht: 157cm beneprotein 2 times a day as
Tiongson pRBC Anemia very severe Wt: 45kg snacks – HOLD (06/05) 05/30
prob secondary to 1) Chronic BMI: 18.3 (underweight) Heplock s/p BT of 9.1 L 0.30 L 20.7 H 84 9 6 1 400
blood loss 2) Chronic disease 2u pRBC Hypovolemic shock (resolved)
(malignancy) 3) Nutritional 05/29 5.2L 0.19L 18.9H 80 12 7 1 544H secondary from severe anemia
Transaminitis from Ischemic Hypovolemic shock s/p BT of 4units pRBC O+/NR probably secondary to
Hepatopathy (resolved) secondary from Diphehydramine 50mg IV 30 Urinalysis 1) Chronic blood loss
Infectious Diarrhea severe anemia probably minutes prior to BT-given 2) Chronic disease (malignancy
Complicated UTI, corrected secondary to Paracetamol 300mg IV 30 Date Sugar Protein WBC RBC Epithelial Bacteria 3) Nutritional
Hypoalbuminemia 1) Chronic blood loss minutes prior to BT-given s/p BT of 4units pRBC
Multiple electrolyte 2) Chronic disease Calcium gluconate 10% 10cc 06/01 Neg Trace 1-2 51-75 H Few Few
imbalance (Hypovolemic, (malignancy) SIVP post BT of 3u PRBC – given IM-Cardio Notes (06/01)
Hypoosmolar, Hyponatremia 3) Nutritional STANDBY Norepinephrine 16mg 05/29 Neg Neg 15-20 H 0-2 Few Few No recurrence of hypotension,
and hypokalemia) secondary (-) hypotension + D5W 500mL to run at Chemistry: cardio signing out
to poor oral intake, corrected (-) loss of consciousness 18cc/hr(0.2mcg/kg/min) to Date BUN Crea Na K AST ALT Cl iCa Mg Phos Trop I Albumin
Underweight (-) DOB/SOB regulate at increments of +/- 06/10 33.57 L IM Hema 06/04
(-) tachycardia 3cc/hr every 15 minutes to 06/09 134.86 L 3.84 Elevated platelet count can be
(-) slight pallor maintain BP =90/60mmHg (max: 06/08 133.19 L 3.48 L 68.56 H 29.81 attributed to possible
(-) generalized body 54 ugtts/min) 134.78 L 4.00 97.42 0.8 1.08 25.72 L malignancy
weakness 06/07 Monitor CBC for now, no hema
3
(-) dizziness 133.52 L 4.56 1.15 0.8 0.86 referral warranted
pink palpebral conjunctiva 06/05 2.00 22.51
2
Last hypotension: 05/29:
06/05 132.41 L 24.84 L
70/40  Norepinephrine
129.47 L 3.56 105.61 H 28.78 0.7 1.39
110/70 06/04 2.16 28.36 L Transaminitis from Ischemic
8
Hepatopathy
129.51 L 4.9 94.91 L 0.8 1.79 H 26.34 L
Transaminitis from Ischemic 06/03 2.08 L 28.24 L GASTRO NOTES (06/08)
1
Hepatopathy Continue Essential
(-)change in sensorium Essential Phospholipid caps, 2 134.74 4.90 0.7 0.96 phospholipids TID
06/02
(-) jaundice caps 3x/day 5
(+) intermittent abdominal 3.40 L 130.04 H 34.92
06/01
pain H
(-) chest pain 136.44 3.14 L 0.7 0.63 L
05/31 2.12 L 28.85 L
(-) DOB/SOB 5 Infectious diarrhea
(-) vomiting 138.21 3.73 0.7 17.16 L Referred to Dr Manayon
05/30
7 regarding CT scan official result
Infectious diarrhea 05/29 130.25L 3.19L 16.66 L and latest albumin-awaiting
(+) 2 episodes of loose 125.02 L 2.68 L 120.91 H 36.72 94.57 L 1.01 0.8 0.96 0.31 notes
stools Ciprofloxacin 500mg tab 1 tab 05/29 1.84 34.43
H 3
(+) tenderness on every 12 hours (D4) Coagulation studies Gastro Notes (06/10)
hypogastric area Racecadotril 100mg/tab 1 tab Date PT % Activity INR APTT Normal WAB CT with UVC
(-) weakness every 8 hours until 2 formed 05/08 13.3 91.0 1.19 33.8 results
stools Will update service consultant
05/30 15.2 H 75.6 1.37 H 39.4
06/09 1300H: watery stools Probiotics sachet 1 sachet once Continue Ciprofloxacin 500mg
05/30 17.0 66.2 1.55 39.0
at 3x greenish, rotten egg a day tab 1 tab every 12 hours for 3
05/29 18.2 61.6 H 1.67 37.1
smell, associated with Oresol volume per volume more days
abdominal pain replacement Tumor markers Noted gyne onco and surg onco
HNBB 10mg TIV every 8 hours Date CA 125 CA 19-9 referrals
05/30 32.22 13.41
Hypoalbuminemia Reticulocyte count (05/29 OSMAK): 5.2H
(-) edema PBS (05/30/24) Hypoalbuminemia
(-) fatigue Platelet: SLIGHTLY INCREASED
(-) DOB RBC: MODERATE MICROCYTOSIS,HYPOCHROMIA WITH ANISOCYTOSIS AND POIKILOCYTOSIS ( TARGET CELLS,BURR CELLS,FEW SPHEROCYTES). Gastro Notes (06/07/24)
(-) loss of appetite Human Albumin 20% vial/ vial WBC: NO ABNORMAL CELLS SEEN For Human Albumin 20% vial/
every 12 hours for 3 days CRP (05/29 OSMAK): >10.00 H vial every 12 hours for 3 days
Multiple electrolyte (completed 06/10 0800H) Ferritin (05/29 OSMAK): 43.97 Post albumin infusion, albumin
imbalance (Hypovolemic, 12L ECG (05/29 OSMAK): NSR
Hypoosmolar, Fecal occult blood (05/29 OSMAK): Negative Multiple electrolyte imbalance
Hyponatremia and BEDSIDE PT (5/29/24): NEGATIVE (Hypovolemic, Hypoosmolar,
hypokalemia) secondary to Fecalysis Hyponatremia and
poor oral intake, corrected Glutaphos tab 1 tab 3x/day Date WBC RBC Other hypokalemia) secondary to
(-) chest pain KCl 750mg/tab 2 tabs PO every 4 NO INTESTINAL watery poor oral intake, corrected
06/09 40-50 5-10
(-) DOB/SOB hours x 2doses only – given PARASITE SEEN Referred back to Dr Espiritu for
(-) dyspnea NO INTESTINAL latest K result and correction-
06/04 >100 10-15 watery
(-) anorexia PARASITE SEEN awaiting notes
(-) diarrhea Imaging
CECT of the Abdomen CLINICAL DATA: 5-month history of gradually enlarging pelvoabdominal mass with unintentional weight loss IM-Nephro notes (06/10)
Cranial nerves OSMAK COMPARISON: None Diet c/o NST
II, III: (+) 3mm EBRTL 06/07/24 TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained with oral, rectal and intravenous contrast. Noted repeat labs
III, IV, VI: (+) EOMs, primary FINDINGS: Since within normal results of
gaze midline Na, K, respectfully signing out,
V: V1-V3 intact A 11.1 x 14.3 x 13.7 cm (ApxWxCC) lobulated, heterogeneously enhancing mass with areas of necrosis and internal air refer back if warranted
VII: No facial asymmetry pockets arising from the pelvic region extending into the peritoneal cavity. It is compresses on the urinary bladder,
VIII: (+) gross hearing intimately related to its superoposterior wall with no distinct fat planes. It severely compresses on the rectosigmoid and NST Notes (06/02)
IX, X: Can swallow descending colon but maintains fair planes of differentiation. It is also seen mildly compressing some of the small bowels Revise diet to 1350 (SF 30) with
XI: Good shoulder shrug (jejunum) and left common iliac vein, also maintaining good planes of differentiation. The uterus and ovaries are not PF 1.5
XII: tongue midline clearly delineated. Minimal fluid collection is seen in the pelvic space. Using regular diet divided into
meals and 2 snacks with the ff
Motor The liver is enlarged with a span of 16.3 cm. Diffuse decrease of parenchymal attenuation with smooth borders is noted. (1.5) CHON 68 g 270 kcal
RUE 5/5 LUE 5/5 Intrahepatic ducts are not dilated. The main portal vein is patent but dilated with a maximum diameter of 1.6 cm. No CHO 160 650
RLE 5/5 LLE 5/5 abnormal enhancement after contrast infusion. CHO 160 650
Fats 50 430
Sensory 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 Continue ORS with beneprotein
RUE 100% LUE 100% or abnormal parenchymal enhancement observed. Start 24 hour food recall c/o
RLE 100% LLE 100% The normal-sized gallbladder exhibits no abnormal intraluminal densities. Wall is not thickened. Common duct is not dietary
dilated.
Complicated UTI, resolved The pancreas is normal in size and configuration. Pancreatic duct is not dilated.
(-) dysuria The adrenal glands are normal without undue enhancement. Complicated UTI, resolved
(-) fever Both kidneys are normal in size and exhibit symmetrical parenchymal enhancement. A few non-enhancing hypodense For antibiotic completion
(-) chills 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-
(-) increased urine 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 IM-IDS notes (06/04)
frequency Ceftriaxone 2g TIV once a day evidence of opaque lithiasis or hydronephrosis. Continue Ceftriaxone 2g TIV OD
(completed) The appendix is not dilated. The included esophagus, stomach and intestinal segments are grossly normal. until Day 7, IDS respectfully
Gyne wise Prominent and enlarged lymph nodes are seen in the left paraaortic, mesenteric, and right iliac chains, with the largest signing out
No profuse vaginal bleeding detected in the right iliac chain measuring 1.8 cm along its short-axis diameter.
No severe hypogastric pain Minimal osteophytes are seen along the margins of the visualized spine. Sclerotic foci are seen in the T9 and L5 vertebral Gyne wise
bodies. The lumbar lordosis is straightened. For possible endometrial biops
G2P2 (2002) No meds for now Diffuse subcutaneous stranding densities are noted. For referral to gyne onco in Jun
LMP: Last week of March Reticulonodular densities are seen in both visualized lower lobes. 13,2024 – rotator informed (Dr
2024 Pesigan)
PMP: Unrecalled Impression: Daily body and perineal hygien
PMP: Unrecalled - Large and enhancing pelvoabdominal mass with areas of necrosis, extension and mass effects, as detailed. Neoplasm is Monitor vs q4
the primary consideration. Tissue correlation is advised Strict I and O
soft flabby abdomen, - Hepatosplenomegaly with signs of portal hypertension. Please correlate with pertinent parameters WOF: severe abdominal pain,
palpable hypogastric mass - Peritoneal and pelvic lymphadenopathies nausea and vomiting, DOB/SOB
from below the umbilicus to - Minimal pelvic ascites chest pain, weakness
hypogastric area, telect. - Left renal cysts (Bosniak I and II)
13x9cm size, nonmovable - Diffuse subcutaneous edema IM Pulmo (05/29)
with direct tenderness on - Degenerative osseous changes Referred to Dr. Arguila
palpation - Sclerotic foci, T9 and L5 vertebral bodies, may represent bone islands, however, metastatic process is not entirely ruled Cleared for regular ward
out if with proven malignancy. Follow-up is suggested Respectfully signing out
SE: Cervix flushed to the - Straightened lumbar lordosis likely due to muscle strain
vault, no mass, no erosions, - Reticulonodular densities, both lower lobes. Consider an inflammatory/infectious process. Please correlate clinically SURGERY Notes (06/10)
no bleeding per os UTERUS: 20.72x12.18x10.98cm Dr. Gomez updated
TVS shows an enlarged uterus, heterogenous, with irregular solid components, with moderate color on color flow Noted plans for chest CT with
IE: cervix flushed to the mapping IVC
vault, closed, uterus cannot ENDOMETRIUM not delineated noted OB plans for endometria
be palpated due to enlarged CERVIX: 3.38x2.78cm biopsy
mass TVS UTZ c/o OB sono (05/31/24 OSMAK) Suggest CA 19-9 and CEA
RO: not seen
LO: not seen Noted plans for referral to gyne
Impression: onco
Pelovoabdominal mass probably uterine in origin, t/c a non-benign pathology For referral to surg onco (Dr.
Endometrium and bilateral ovaries not visualized Lay-lay)
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 Urology (06/04) referred back
cm with cortical thickness of 0.9 cm. There is no evidence of hydronephrosis, lithiasis or mass noted in both kidneys. The to Dr Copuyoc for WAB CT
KUB UTZ urinary bladder is adequately distended. Its wall appears to be thickened measuring 0.7 cm. An indwelling foley catheter result
OSMAK balloon is seen within.There is incidental note of increased hepatic parenchymal echogenicity with minimal fluid in the Noted WAB CT with triple
(5/30/24) perihepatic space. contrast on 6/7-done
Impression: No immediate surgical
Minimal perihepatic ascites. Incidental note of hepatic steatosis. Unremarkable ultrasound of both kidneys. Nonspecific intervention
urinary bladder wall thickening. Correlate clinically. Please refer back once with
Focused scanning of the hypogastric/pelvic region shows an ill-defined, heterogeneous mass with internal calcifications WAB CT scan results
and with moderate vascularity upon Doppler interrogation, measuring approximately 11.4 x 12.6 x 10 cm. It has apparent Dr. Zalueta updated
extension into the superoposterior portion of the urinary bladder. The right ovary is normal in size measuring 2.8 x 2 x 2.6 Provide adequate analgesia
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) Pending Labs
IMPRESSION:
Pelvoabdominal mass with possible urinary bladder extension. Pelvic MRI is recommended for further evaluation. [ ] For Chest CT scan with IVC
Normal sonogram of the right ovary. Non-visualized left ovary (on June 14, c/o Dr. Capuchino
Chest / Abdomen xray (05/29/24 OSMAK) Chest: [x] Urine CS – not amenable
An ovoid opacity is noted in the left upper lung. Pulmonary vascular markings are within normal limits. The heart is not With refusal form
enlarged. Both hemidiaphragms and costophrenic angles are intact. Bony thorax is unremarkable. [x] Blood CS x 2 sites – not
Impression: amenable
Consider pulmonary granuloma, left upper lung With refusal form
[ ] repeat ABG not amenable
Abdomen: With refusal form
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. *Patient and relative amenable
The visualized bones are intact. for surgical procedure
Impression:
Fecal retention Advance directives (05/29/24)
Yes to all
Stool charting
06/09 3 watery stools, greenish, rotten egg smell
06/05 4 loose stools
Gyne 3 G3P2(2012) BPR 130-140/80-90 Soft diet with SAP CBC with PC
ALTA, MARIA SALOME Endometrial Endometrioid BP 130/80 IVF: PLR 1L x 8 hours Date Hgb Hct WBC S L M E Plt
ASENETA Carcinoma FIGO Grade 2 HR 80 06/11 10.3 0.29 17.8 81 12 5 2 200 06/07 – 1st session in HD
63 Stage IB RR 20 06/08 – 2nd session in HD
06/04 13.2 0.39 13.1 81 11 7 1 457
YC AKI St III probably secondary T 36.7 Still for scheduling – 3rd session
B+/NR
to acute pyelonephritis
Urinalysis
06/04/2024 Post-operative ileus I: 1200
190223 t/c Acute pyelonephritis O: 2100 Date Sugar Protein WBC RBC Epithelial Bacteria
Dr. Alfabeto/Tungcul/ Gavino, from t/c partial gut 06/04 Neg 2+ 29.5H 5.6 154.9 65.1
Roque (TL) /Posadas, obstruction Ht: 155.2cm Chemistry:
Tugado/Tiongson, Jasarino Acute gastroenteritis, no Wt: 63.6kg Date BUN Crea BUA Na K Mg Cl Phos AST ALT HbA1c
signs of dehydration, BMI: 26.1 (Obese I) 06/11 11.16 150.35 H 141.53 3.40 L 0.61 L 1.10
0948H/ 1248H resolved Acute gastroenteritis with no
EBL: 450 cc Diabetes Mellitus type II Acute gastroenteritis with 06/07 35.09 H 687.30 H 141.09 4.03 0.89 2.34 H signs of dehydration
Hypertension Stage II no signs of dehydration 06/06 34.00 H 738.84 H For observation of recurrence o
Multinodular toxic goiter, (-) epigastric pain loose stools
06/06 33.77 H 789.30 H 136.67 4.03 0.92
clinically and biochemically (-) nausea None for now
euthyroid (-) vomiting 06/05 30.36 H 756.67 H
Hypokalemia secondary to (-) recurrence of loose stools 06/05 27.04 H 734.44 H 132.83L
suboptimal intake (-) dry lips
(-) sunken eyeballs 06/04 22.57 H 704.29 H 4.55 93.56L 28.24 40.80 5.40
s/p Ultrasound-guided IJ last episode: 06/05 0530H, 05/28 5.12 59.82 423.49H 139.34 3.93 105.09 34.53 51.98
catheter insertion, Right semiformed AKI St III probably secondary t
Coagulation studies
(6/6/2024) acute pyelonephritis
Date PT % Activity INR APTT
s/p Exploratory Laparotomy, AKI St III probably For HD (next schedule: 06/10)
06/04 12.6 96.2 1.12 32.3
Peritoneal fluid cytology, secondary to acute For repeat KUB UTZ after 1
Extrafascial hysterectomy, pyelonephritis Thyroid Function tests week to rule out
bilateral (-) fever None for now Date FT3 FT4 TSH hydronephrosis (will not do for
salpingoophorectomy, (-) edema 05/28 2.80 1.23 2.90 now, unless clinically indicated
Bilateral lymph node (-) DOB/ SOB Fecalysis
dissection under CLEA (-) dysuria Date WBC RBC Other Others IM Nephro (06/10/24)
(5/30/2024) (-) hematuria 06/04 0-2 0-2 NO INTESTINAL PARASITE SEEN BUDDING YEAST CELLS – MODERATE Deck to HD today with the ff
Day 9 12L ECG (06/04/24 OSMAK): NSR, normal axis, no hypertrophy, no ischemic changes settings:
Pregnancy Test (5/28 OSMAK): negative UF 2L Qd 250 Qd 500 BUR 4H
s/p Ultrasound Guided IJ Ferritin (06/04 OSMAK): 710.80H Heparinized (Priming none,
Catheter insertion, right Hepatitis profile (06/07) treatment LMWH) IJ cath,
under MAC regular
For repeat labs tomorrow:
TEST NAME OBSERVED VALUE NORMAL RANGE [ ] BUN, Na, K, Mg, Phos, CBC
HEPATITIS PROFILE with PC
[HbsAg] 0.48 < 1.0 Urology 06/07/24)

[HbsAg Remarks] NONREACTIVE Retrograde pyelography not
[Anti-HCV] 0.09 < 0.9 indicated for now
No immediate surgical
[Anti-HCV Remarks] NONREACTIVE
intervention
[Anti-HBc IgG] 2.03 1.00 Repeat KUB UTZ after 1 week t
[Anti-HBc IgG Remarks] NONREACTIVE rule out hydronephrosis
[Anti-HBs] <2.00 < 10 Continue present management
Dr. Cuaresma updated
[Anti-HBs Remarks] NONREACTIVE
Imaging
WAB CT scan with IVC (6/8/24) Findings: IM Cardio (6/8)
Post-surgical changes are seen mid-lower abdomen. The uterus is surgically absent. There are small non-enhancing fluid Noted s/p access creation,
collections (some with small air locules) seen in the mid pelvic region (adjacent the vaginal stump) and along the left lower respectfully signing out
abdomen / pelvic side wall.
The stomach is under distended (NGT noted). The large bowel loops appear grossly unremarkable. There are dilated jejunal bowel
segments with no distinct transition point (maximal transverse diameter of 3.5 cm). There is also mild wall thickening of some
small bowel loops in the left abdomen. The appendix is not dilated. There is a small fat-containing umbilical hernia.
The liver is normal in size with smooth margins. No enhancing focal masses seen. There is no intrahepatic or extrahepatic biliary Hypokalemia secondary to
ductal dilatation. There are no calcified intraluminal filling defects seen in the gallbladder. The gallbladder wall does not appear suboptimal intake
thickened For K correction
The spleen appears unremarkable. Referred to IM-Nephro
There is fatty degeneration of the pancreas. The pancreatic duct is not dilated. (Dr. Vizcaya)
The adrenal glands are unremarkable.
Both kidneys are normal in size and position. Minimal nonspecific bilateral perinephric stranding densities are seen. The
pelvocalyceal systems and ureters are not dilated. There is no evidence of mass or lithiasis.
Hypokalemia secondary to The urinary bladder is under distended with an indwelling Foley catheter in place.
suboptimal intake No meds for now There are no enlarged peritoneal / retroperitoneal lymph nodes
(-) weakness Segmental calcifications are seen along the abdominal aorta and some of its branches.
(-) dizziness Osteophytes are seen along the margins of the visualized spine. There is multilevel facet arthrosis. Sclerotic foci are seen in the
right ilium, greater and lesser trochanter of the right femur, and left acetabulum, representing bone islands. There is corduroy
appearance of the T8 and T9 vertebral bodies.
Reticulonodular and ground glass densities are seen in the visualized middle lobe segments and lingular segments. Linear
densities are seen in the visualized middle lobe segment and left lower lung segments.
IMPRESSION:
- S/P TAHBSO. Note of non-enhancing small fluid collections (some with air locules) in the mid pelvis / left pelvic side, may still be
post-surgical in origin
- Ileus
- Note of mild wall thickening of several small bowel loops in the left hemiabdomen, may be inflammatory in origin
- Small fat-containing umbilical hernia
- Fatty degeneration of the pancreas
- Minimal nonspecific bilateral perinephric fat stranding, may relate to an inflammatory process. Correlate clinically. Post-operative ileus
- Atherosclerosis t/c Acute pyelonephritis
- Degenerative changes of the spine from t/c partial gut obstructio
- Consider vertebral hemangiomas, T8 and T9 referred back to Dr Copuyoc fo
- Reticulonodular and ground-glass densities, middle lobe and lingula. Consider Koch’s vs non-Koch’s pneumonia Subsegmental final diagnosis of PGO
atelectasis versus fibrosis, middle lobe and left lower lobe
Previous study dated June 7, 2024 was reviewed.
Correlation with CECT of the Whole Abdomen done June 8, 2024 was done. SURGERY 06/10
Present study shows further decrease in the caliber of the gas-filled small and large bowel segments. No differential air-fluid Please facilitate KUB UTZ next
Post-operative ileus Cefuroxime 750mg IV q8 (D6) levels noted. week
t/c Acute pyelonephritis Metronidazole 500mg IV q8 No organomegaly appreciated. Continue present management
from t/c partial gut (D6+1) The rest of the soft tissue do not appear unusual. Refer back once with UTZ
obstruction Omeprazole 40mg IV q12h Abdomen Upright-Supine (6/9/24)
Osteophytes are seen lining the margins of the visualized spine.
(-) Abdominal pain Partially visualized feeding tube is noted along the left upper quadrant. Diabetes Mellitus type II
(-) Nausea and vomiting Retained contrast media is seen along the large bowel segments. IM-Endo notes (06/09)
(-) Anorexia IMPRESSION: Patient seen and examined
(-) loose stools Non-specific non-obstructive bowel gas pattern Continue insulin Glulisine slidin
Last BM: 06/08 0600H Degenerative changes of the visualized spine scale
Consider decreased degree of small bowel obstruction
Abdominal Xray (06/07/24) IM NST 06/09
Degenerative osseous changes
Consider decreased degree of small bowel obstruction Continue current diet for now
Degenerative osseous changes
Chest/ Abdominal X-ray official (06/06) Hypertension Stage II
Unchanged degree of small bowel obstruction For BP monitoring and record
Degenerative osseous changes Continue antihypertensive med
Insulin Glulisine sliding scale SC Findings – patient’s stocks
Diabetes Mellitus type II 180-220 4u Both kidneys are normal in size with smooth and regular contour and increased parenchymal echogenicity.
(-) polyphagia 220-260 6u The cortico-medullary pattern in both sides is intact.
(-) polydipsia 261-300 8u The right kidney measures 10.3 x 4.8 x 5.6 cm with cortical thickness of 0.9 cm.
(-) polyuria >300u 10u, refer to IMROD The left kidney measures 9.9 x 5 x 4.2 cm with cortical thickness of 0.7 cm. Multinodular Goiter clinically
See CBG table KUB UTZ (06/06, OsMak) There is no evidence of hydronephrosis, lithiasis or mass noted in both kidneys. and biochemically euthyroid
The urinary bladder is underdistended with a volume of 98 ml, precluding optimal evaluation. A Foley catheter balloon is noted IM ENDO (6/9/24)
within. Repeat TFT (FT3, FT4, TSH) afte
Impression: 6 weeks (July 10, 2024)
- Underdistended urinary bladder with Foley catheter
- Normal sized kidneys with sonographic signs of parenchymal disease. Correlate clinically.
Abdominal Xray 06/05 Unchanged Ileus Gyne Wise
Still considering SBO Definitive plan: For vaginal
Bowel diameter: 6cm brachytherapy; possible EBRT
Previous study dated June 2, 2024 was reviewed. For gradual diet progression, fo
The dilated gas-filled small bowels are again seen. monitoring of creatinine trends
Obliquely oriented rows of small gas bubbles are seen. hemodialysis c/o Nephro servic
Few differential air-fluid levels are identified. For serial abdominal
Rectal gas is apparent. examination
Flank stripes and psoas shadows are intact. every 4 hours c/o OB ROD
There are no abnormal intra-abdominal calcifications. VSq4h for now
Hypertension Stage II The soft tissues do not appear unusual. Incentive spirometry 10-15x
(-) headache Abdominal Xray 6/4 Dr. Catanaoan /hour q waking hours
Osteophytes line the visualized lumbar spine and bilateral anterior superior iliac spines.
(-) dizziness Metoprolol 100mg/tab, 1/2 tab Impression: Encourage careful ambulation,
(-) nape pain OD Consider beginning small bowel obstruction. Close follow-up is suggested deep breathing exercises
(-) chest pain Amlodipine 10mg/tab, 1 tab OD Degenerative osseous changes Apply compression stockings q
(-) DOB/SOB Atorvastatin 20mg/tab,1 tab OD -------------- hours on/off
(-) chest pain Follow-up study was done on June 5, 2024 showing no significant change in the dilated gas-filled bowels. The rest of the WOF: severe hypogastric pain,
(-) orthopnea abdominal findings are unchanged. profuse vaginal bleeding
Bowel diameter: 5.8cm
Multinodular Goiter, Previous study dated May 28, 2024 was reviewed. Pending:
clinically and biochemically The lungs are hypoaerated with bronchovascular crowding. [ ] For repeat BUN Crea Na K, C
euthyroid No meds for now The heart is magnified. 24 hours post 3rd HD (tentative
(-) palpitations Calcifications are seen along the aortic walls. 06/11)
(-) tremors Both hemidiaphragms and costophrenic sulci are intact. [ ] TSR urine CS c/o ACE patero
(-) chest pain CXR 06/04 Osteophytes are seen lining the margins of the visualized spine. (06/10)
(-) DOB/SOB There is an interval placement of a feeding tube with its tip within the gastric bubble. [ ] Repeat TFT (FT3, FT4, TSH)
Impression: after 6 weeks (July 10, 2024)
Gyne Wise Low lung volume [ ] KUB UTZ after 1 week (June
No hypogastric pain Atheromatous aorta 13,2024, 9-10 AM) c/o Dr/
No profuse vaginal bleeding None Degenerative osseous changes of the visualized spine Obsum
(+) well coaptated post-op The gas-filled small bowels are dilated with maximum diameter of 5.1 cm. No differential air-fluid levels identified. [X] Ideally for ABG – refused
scar Rectal gas is apparent.
No erythema or discharge Flank stripes and psoas shadows are intact.
There are no abnormal intra-abdominal calcifications.
Abdominal girth: Abdomen supine-upright 06/02/2024,
The soft tissues do not appear unusual.
06/10 105 cm OSMAK
Osteophytes line the visualized lumbar spine and bilateral anterior superior iliac spines.
06/09 106cm Impression
06/08 109cm Ileus. Short interval follow-up is recommended.
06/07 104cm Degenerative osseous changes
06/06 104cm Clinical data: Known case of endometrial cancer; for metastatic work-up
06/05 102 cm Comparison: None
Findings:
The liver is normal in size with increased parenchymal echogenicity.
There are no focal mass lesions noted.
The intrahepatic ducts are not dilated.
The gallbladder is normal in size measuring 5 x 2.3 cm.
Its wall is not thickened measuring 0.2 cm. No pericholecystic fluid seen.
There are no intraluminal echoes or focal lesions noted.
The common duct is not dilated to the extent visualized measuring 0.3 cm.
The visualized pancreas and spleen are normal in size and echotexture.
WAB UTZ 05/29/2024 There are no focal lesions appreciated.
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 x 5.4 x 3.3 cm with cortical thickness of 0.8 cm.
The left kidney measures 9.5 x 4.2 x 3.8 cm with cortical thickness of 0.7 cm.
There is no evidence of hydronephrosis, lithiasis or mass noted in both kidneys.
The urinary bladder is under-distended with volume of 15 mL.
There are no intraluminal echoes or focal mass seen.
Impression
Mild fatty liver
Underdistended urinary bladder
Unremarkable sonogram of the gallbladder, visualized pancreas, spleen and both kidneys
Chest x-ray (05/28 OSMAK) Previous study dated March 8, 2024 was reviewed.
Present study shows no active parenchymal opacities in both lungs.
Pulmonary vascular markings are within normal limits.
Heart is enlarged.
Some calcifications are seen along the walls of the aorta.
Both hemidiaphragms and costophrenic angles are intact.
Osteophytes line the margins of the visualized spine.
Impression:
Cardiomegaly
Atherosclerotic aorta
Thoracic spondylosis
The uterus is anteverted with smooth contour and homogeneous echopattern measuring 5.05 x 5.31 x 2.69 cm.
The cervix measures 2.86 x 2.52 × 1.93 cm with homogeneous stroma and distinct endocervical canal.
The endometrium measures 1.43 cm, with mixed echogenicity, heterogenous, midline echo not defined, irregular endometrial-
myometrial junction, strong color on Doppler (color score 4).
The right ovary measures 1.50 x 1.10 x 0.97 cm (vol: 0.87 ml) with several follicles less than 1 cm in diameter.
The left ovary measures 1.47 x 1.35 x 0.68 cm (vol: 0.71 ml) with several follicles less than 1 cm in diameter.
Transvaginal/Transabdominal UTZ
There is no fluid in the posterior cul-de-sac.
(1/11/24) – Makatilife
Impression:
NORMAL-SIZED, RETROVERTED UTERUS WITH A THICKENED ENDOMETRIUM WITH STRONG FLOW ON COLOR MAPPING
SUGGESTIVE OF ENDOMETRIAL PATHOLOGY.
ATROPHIC OVARIES.
NO UTERINE OR ADNEXAL MASS.
NO FLUID IN THE POSTERIOR CUL-DE-SAC.
CBG monitoring
Date 0000H 0400H 0800H 1000H 1200H 1600H 2000H
06/10 109 103
06/09 DISCONTINUED
06/08 89 94 102 - 86 83 88
06/07 96 97 96 - 90 83 84
06/06 92 97 97 - 105 84 94
06/05 - - 130 109 103 85 83
IE under anesthesia: Normal external genitalia, smooth vagina, cervix 2x2 cm, no adnexal masses, intact rectovaginal septum, bilateral parametria smooth and pliable.
There was no ascites. The liver, peritoneum and subdiaphragmatic surface, stomach, spleen, kidneys, small intestines, large intestines, mesentery, appendix and bladder were smooth and
grossly normal on inspection and palpation. There were no palpable pelvic or paraaortic nodes.
The uterus measured 6.0 x 5.5 x 3.0 cm, with a smooth and tan serosal surface. The cervix was not dilated and uneffaced with a smooth ectocervix.
The right ovary was atrophic; measuring 2.5 x 1.5 x 1.0 cm; the left ovary is likewise atrophic measuring 2.0 x 1.0 x 1.0cm
The right fallopian tube measured 7.0 x 0.5 x 1.0 cm
The left fallopian tube measured 6.0 x0.5 x 0.5 cm.
The right and left pelvic lymph nodes, were noted to be several pieces of yellow tan, fibrofatty tissue. The right pelvic lymph nodes measured 5.0 x 4.0 x 1.0 cm. The left pelvic lymph nodes
measures5.0 x 4.0 x 1.0 cm.
Noted with 3 subcentimeter myoma nodules on the anterior mid portion, right lateral anterior portion, and right lateral portion of the uterus
Histopathology findings (06/05/2024)

SPECIMEN: UTERUS; RIGHT AND LEFT FALLOPIAN TUBE; RIGHT AND LEFT OVARIES; RIGHT AND LEFT PELVIC LYMPH NODES
A,B AND C. S/P HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY AND LYMPH NODE DISSECTION
-- ENDOMETRIAL ENDOMETRIOID CARCINOMA, NOT OTHERWISE SPECIFIED, FIGO GRADE 2
-- TUMOR INVADES ONE-HALF (50%) OF MYOMETRIAL THICKNESS
-- MYOINVASIVE LOWER UTERINE SEGMENT INVOLVEMENT PRESENT
-- TUMOR DOES NOT INVADE THE STROMAL CONNECTIVE TISSUE OF THE CERVIX
-- LYMPHOVASCULAR INVASION NOT IDENTIFIED
-- ALL MARGINS NEGATIVE FOR CARCINOMA
-- ALL 6 REGIONAL LYMPH NODES (3 RIGHT PELVIC, 3 LEFT PELVIC), NEGATIVE FOR TUMOR CELLS
-- NEGATVE FOR TUMOR INVOLVEMENT: RIGHT AND LEFT PARAMETRIA; RIGHT AND LEFT FALLOPIAN TUBES
-- ADENOMYOSIS
-- SUBSEROUS AND INTRAMURAL LEIOMYOMAS
-- CHRONIC CERVICITIS
PERITONEAL FLUID: CYTOLOGY AND CELL BLOCK
-- NEGATIVE FOR MALIGNANT CELLS
-- REACTIVE MESOTHELIAL ATYPIA PRESENT
Gyne 4 G3P3 (3003) BPR 100-110/70-80 DAT with SAP CBC with PC
ADRIATICO, ROWENA DE LA Poorly differentiated BP 120/80 Start ensure Gold + 2 scoops Date Hgb Hct WBC S L M E Plt
REA carcinoma with mucinous HR 100 Beneprotein 2x as snacks 06/08 s/p
59 features, cervix stage IIB RR 20 IVF: Heplock BT of 3u 10.2 L 0.31 L 35.2 H 89 H 4 7 0 187
NYC Menopause x 9 years T 37.4 (+) cardiac monitor pRBC
Blood transfusion of 3 units O2 sat 97% (+) O2 support FM @ 10 LPM
06/04 9.4 L 0.29 L 41.3 H 89 H 5 5 6 152
05/28/2024 pRBC for anemia severe
101224 secondary to malignancy, I: 2275 06/02 11.1 0.34 39 H 88 H 5 7 227
Dr Alfabeto/ Tungcul corrected O: 1420 06/01 10.4 L 0.32 L 34.1 H 87 H 6 7 - 196
Ballesteros(TL)/Gavino/ De Hyponatremia, probably 05/29
Guia Gauiran/Kadappurath secondary to suboptimal Ht: 157cm s/p BT of 11.8 0.36 36.4 H 90 H 5 5 271
Tiongson intake Wt: 45kg 2u pRBC
Hypokalemia, BMI: 18.3 (underweight) 05/28 7.5 L 0.23 L 39.9 H 87 H 8 5 - 388
Hypomagnesemia secondary O+/NR
to suboptimal intake, Last febrile episode 06/10 Urinalysis Anemia severe secondary to
corrected 0030H  37.7  TSB  malignancy, corrected
Date Sugar Protein WBC RBC Epithelial Bacteria
Pleural effusion (bilateral) 37.4 s/p BT of 3u pRBC
probably secondary to 1) t/c 06/03 NEG Trace 2.0 2.8 32 8.8
parapneumonic process Anemia severe secondary s/p BT of 3u pRBC 05/28 Neg Neg 15-18 H 2-4 Few Moderate
2) paramalignant process to malignancy, corrected Pre-BT meds: TFTs
Subclinical Hypothyroidism (-) hypotension 1) Diphenhydramine 50mg TIV- Date FT3 FT4 TSH
t/c fever of malignancy (-) dizziness given 06/03 0.66 L 0.47 L 3.41
Asymptomatic bacteriuria, (-) generalized body 2) Paracetamol 300mg TIV Coagulation studies ``````
resolved weakness Regulate IVF to KVO during BT- Date PT % Activity INR APTT
Hyperglycemia secondary to (-) pallor given 06/03 15.3 H 74.9 1.38 H 54.1 H
infection slightly pale palpebral Furosemide 40mg TIV post BT- 05/29 15.8 H 71.6 1.43 H 53.0 H Hypoalbuminemia
conjunctivae given Chemistry:
s/p Cervical punch biopsy Calcium gluconate 10% 10cc RBS LDH Total Globulin A/G Na K Mg P Tca Pho Alb Trop ALT IM NST notes (06/09)
(03/21/2024) SIVP post BT of 3u PRBC Date BUN Crea Will not clear for proper diet fo
Protein Ratio s I
now, will correct electrolytes
132.72 3.83
06/11 first
L
Patient referred back to Dr
10.01 132.02 3.31 0.81 0.80 23.33
Hypoalbuminemia 06/10 53.93 Ramirez regarding diet
H L L L
(-) edema Human albumin 20% 1 vial 2x a modification-awaiting notes
127.68 2.54 0.64
(-) fatigue day for 3 days – completed 06/09 11.68H 60.06
L L L
(-) DOB
11.69 240.95 50.75 L 27.90 0.82 22.85 IM Nephro (06/10)
(+) loss of appetite 06/06
H L IVF shift to heplock
136.56 3.94 23.96 15.08 Noted to resume oral feeding
06/02 2.76 50.23 For repeat electrolytes as
Hyponatremia, probably KCL 750mg/tab, 2 tabs every 4 L
133.42 3.22 0.20 previously record
secondary to suboptimal hours for 5 doses 06/01
intake KCL 750mg/tab, 2 tabs every 4 L L
3.37 Hyponatremia, probably
Hypokalemia, hours for 6 doses - completed 05/31
L secondary to suboptimal intak
Hypomagnesemia Mg So4 drip: 1g in 250cc D5W
Hypokalemia,
secondary to suboptimal x24hrs - completed 134 L 3.10 19.22
05/30 Hypomagnesemia secondary
intake, corrected Omeprazole 40mg TIV OD L L
to suboptimal intake, correcte
(-) chest pain Furosemide 40mg/tab, 1 tab 134.57 2.83 0.83 1.82 1.13 17.59
05/29 No active management
(-) DOB/SOB every 8 hours for 3 doses - L L L L
(-) dyspnea completed 05/28 129.67 2.14 0.78
Nephro Notes (06/10/24)
(-) anorexia PM L L
Start ff correction:
125.20 2.44 1. KCL 750mg/tab, 2 tabs every
05/28 2.86 42.08
Cranial nerves L L 4 hours for 5 cycles
II, III: (+) 3mm EBRTL FBS (06/11): 6.24 -> 112.32 2)Human albumin 20% TIV q12
III, IV, VI: (+) EOMs, primary Hba1c (06/10): 5.41 with post furosemide 40 mg
gaze midline PBS (04/30/2024 OSMAK): Repeat Na, K 8 am 06/11
V: V1-V3 intact Platelets: Moderately increased Will give final MRA clearance
VII: No facial asymmetry RBC: Mild microcytosis. Hypochromia with anisocytosis. once electrolytes corrected
VIII: (+) gross hearing WBC: No abnormal cells seen.
IX, X: Can swallow 12L ECG (05/28 OSMAK): ECG Normal sinus rhythm, left axis deviation, no chamber enlargement, no T wave inversion V2-V4
XI: Good shoulder shrug 12L ECG (05/31 OSMAK): Incomplted bundle branch block, left axis deviation
XII: tongue midline Urine CS 05/30, HealthSTAT No growth after 24 hours of incubation
Urine GS 05/30 , HealthSTAT Pus cells 0-1; EC 0-1; No microorganisms seen
Motor Blood CS 05/30, HealthSTAT No growth after 5 hours of incubation
RUE 5/5 LUE 5/5 ABGs
RLE 5/5 LLE 5/5 Date pH pCO2 pO2 HCO3 BE SO2
05/31 7.55 45 105 39.4 15.2 99
Sensory
RUE 100% LUE 100% Imaging
RLE 100% LLE 100% Scanning of the left hemithorax shows free fluid collection measuring approximately 665 ml.
Pleural effusion (bilateral)
Marking was done at the left mid to lower posterior chest wall.
Ultrasound Guided Thoracentesis probably secondary to 1) t/c
Asepsis/antisepsis, local anesthesia infiltration and thoracentesis performed by IM ROD.
OSMAK parapneumonic process
Pleural effusion (bilateral) Meropenem 1g TIV every 8 After insertion of thoracentesis needle, tip was noted to be inside the hemithorax but with no output.
(06/06/24) 2) paramalignant process
probably secondary to 1) hours (Day 5+1) Another attempt of thoracentesis was done; needle observed to enter hemithorax initially but no output was observed.
Immediate plan: For pleural
t/c parapneumonic process Furosemide 40mg TIV q12h (D3) Procedure was eventually deferred.
catheter insertion (with pleura
2) paramalignant process Start Metoprolol 50 mg/tab 1 Chest Xray initial (6/5) on day 3 of
Progression of bilateral pleural effusion, no changes in pulmonary congestion biopsy) c/o Surgery service,
(-) DOB/SOB tab BID Meropenem – c/o Dr. Rafael
awaiting final OR schedule
(-) pleuritic chest pain There is evidence of free fluid collection in both hemithoraces with an approximate volume of at least 273.11 ml on the Referred back to Surgery (Dr.
(-) cough right and 752.35 ml on the left. San Andres) for Thoracic Drain
(-) night sweats Hemithorax Ultrasound (June 2, 2024 There is no evid ence of septations. insertion scheduling and
(-) weight loss OsMak) Atelectasis of the underlying lung is present. approved MARF
Decreased breath sounds IMPRESSION
bilateral bases Bilateral pleural effusion, minimal on right, moderate on left IM CARDIO/MRA Notes
Decreased vocal fremitus Pulmonary congestion. Concomitant pneumonia cannot be ruled out (06/11/24)
CXR (06/01/24 OSMAK) Progression of bilateral pleural effusion Dx: for CXR, 12 LECG
Last desaturation episode: Atheromatous aorta Tx:
06/03 0015H 87% -> 95%  WAB and chest CT SCAN with IV contrast Findings: Start Metoprolol 50 mg/tab 1
FM @ 10 lpm  91% (05/30/24 OSMAK) Multiple, varisized non-calcified, non-enhancing pulmonary nodules are seen in the apical and posterior segments of the tab BID
(0255H) right upper lobe, apicoposterior, anterior and lingular segments of the left upper lobe and in the visualized segments of
both lower lobes. The largest on the right is located in the posterior segment of the upper lobe measuring 0.8 x 0.6 x 0.9
cm (ApxWxCC), while the largest on the left is in the superior lingular segment measuring 0.6 x 0.9 x 0.9 cm. PULMO (06/10)
Moderate amount of fluid is noted in both hemithoraces with atelectasis of the adjacent lung segments. Suggest heplock and limit fluid
Reticular and ground-glass densities are seen in the apicoposterior and lingular segments of the left upper lobe and in intake
the superior segment of the left lower lobe. Linear densities are also seen in the medial segment of the right middle < 1.2 L/day since noted bipedal
lobe, superior lingular segment of the left upper lobe and superior segment of the right lower lobe. edema
Mediastinal structures are in place. The heart is slight enlarged, with minimal pericardial fluid The aorta and great Continue O2 support for now t
vessels are normal in course and caliber. Small intimal calcifications line the aorta. maintain O2 sat > 94%
Trachea and mainstem bronchi are patent with no endobronchial lesion. Continue antibiotic treatment
Prominent lymph nodes are seen in the left infraclavicular, paraesophageal and paratracheal regions with the largest on c/o IDS service
the infraclavicular region measuring 0.9 cm at its shortest diameter.
Sclerotic foci are seen in the T6 vertebra, left humeral head, 3rd left posterior rib and 7th left lateral rib, likely bone Surgery/TCVS Notes (06/10)
islands. Small osteophytes line some of the visualized spine. Still for thoracic drain Insertion
+ pleural biopsy left
Impression: Still awaiting MRA clearance
- Multiple non-calcified pulmonary nodules in both lungs. Consider metastasis. Interval follow-up is suggested. please facilitate electrolyte
- Moderate bilateral pleural effusion with passive atelectasis correction
- Reticular and ground-glass densities in the left upper and lower lobes, may be infectious/inflammatory in etiology To secure 2u FPP for procedure
- Subsegmental telectasis versus fibroses, both lungs surgery
- Paraesophageal, paratracheal and left infraclavicular lymphadenopathy
- Mild cardiomegaly
- Minimal pericardial effusion
- Atherosclerotic vessel disease IDS (06/10)
- Mild degenerative osseous changes Still for pleural catheter
-------------------------- insertion
CECT of the ABDOMEN: Please facilitate pleural fluid
FINDINGS: studies
The cervix and the lower uterine segment are enlarged exhibiting irregular contour with heterogenous enhancement. It Continue Meropenem 1g TIV
is intimately related to the urinary bladder anteriorly and posteriorly to the rectosigmoid colon. A small, subserosal, q8h
round, heterogeneously enhancing lesion is seen in fundal region measuring 0.9 x 0.9 x 0.9 cm. Endometrium is fluid No objections for procedure
filled. Both ovaries are not clearly delineated. No objections for THOC
There is circumferential wall thickening of the rectum with a maximum thickness of 1.6 cm. Perirectal stranding densities
are noted. The included esophagus, stomach and the rest of the intestinal segments are grossly normal.
Prominent to enlarged, enhancing and necrotic lymph nodes are seen in the right retrocrural, peripancreatic, aortocaval,
paraaortic, mesorectal and bilateral common and internal iliac chains. The largest is seen in the aorto-caval region
measuring 3.9 x 3.4 x 4.6 cm. Subclinical Hypothyroidism
Fluid is seen in the perihepatic, perisplenic, bilateral paracolic and pelvic regions. IM Endo (06/10)
The liver is not enlarged with smooth contour. Intrahepatic ducts are not dilated. Portal vein is patent. No abnormal Referred to Dr. Ambra
Subclinical Hypothyroidism None for now enhancement after contrast infusion. Repeat FT3, FT4, TSH after 6
(-) palpitation The gallbladder is normal in size. Mutiple calcific densities are seen aggregately measuring of 2.5 cm. Wall is not weeks
(-) heat intolerance thickened. Minimal pericholecystic fluid is noted. Common duct is not dilated.
(-) increase in weight The pancreas is normal in size and with normal configuration. Pancreatic duct is not dilated.
The spleen and adrenal glands are normal without undue enhancement. Asymptomatic bacteriuria,
Asymptomatic bacteriuria, Fosfomycin 3g/sachet in ½ glass Both kidneys are normal in size and exhibit prompt and bilateral nephrogram. Non-enhancing, fluid attenuating foci are resolved
resolved of water as single dose- given seen in the left kidney with the largest in the superior pole measuring 2.9 x 2.5 x 2.6 cm. No evidence of hydronephrosis No active management for now
(-) dysuria or opaque lithiasis. Ureters are not dilated.
(-) hematuria The urinary bladder is underfilled with Foley catheter balloon seen within. t/c fever of malignancy
(-) increased urinary Sclerotic foci are seen in the bilateral ilium, right acetabulum, bilateral femoral heads and proximal left femur, likely IM-IDS notes (06/05)
frequency bone islands. Small marginal osteophytes line some of the visualized spine. Noted for thoracentesis c/o
(-) fever Linear subcutaneous hyperdensities are seen in the chest wall, abdominal wall, and proximal thighs. Pulmo
(-) chills Impression: Still for thoracic drain insertion
- Irregular, thickened and heterogenous enhancing cervix and lower uterine segment; known case of cervical carcinoma For CXR post thoracentesis
t/c fever of malignancy Paracetamol 600mg TIV q6 PRN - Circumferential rectal wall thickening, may be extension of malignancy versus infectious/inflammatory in etiology. Ideally for ABG
no recurrence of fever for pain/fever Colonoscopy is suggested for further evaluation. Continue Meropenem 1g TIV
no chills - Diffuse retroperitoneal and pelvic lymphadenopathy, likely metastatic every 8 hours
no generalized body - Ascites For PF cultures GS/CS, PF
weakness - Cholecystolithiases with minimal pericholecystic fluid studies once with sample
- Left renal cysts (Bosniak I)
Last febrile episode 06/04, - Mild degenerative osseous changes Hyperglycemia secondary to
1545, given Paracetamol - Anasarca infection
37.1 Insulin Glulisine sliding scale There is evidence of fluid collection in both hemithoraces with an approximate volume of at least 389 mL on the right For FBS and HBA1c - done
CBG and 453 mL on the left. Referred back to IM Endo (Dr.
Hyperglycemia secondary 181-220: 2u There is no evidence of septations. Ramirez)
to infection 221-260: 4u Hemithorax UTZ (05/29)
Atelectasis of the underlying lung is seen.
(-) decrease in sensorium 261-300: 6u Impression IM Endo (06/10/24)
(-) DOB >300 8u and refer Bilateral minimal pleural effusions, more on the left Continue Insulin Glulisine slidin
Bilateral pleural effusion. Other underlying lung pathologies (eg. Pneumonia) are not ruled out. scale
Chest x-ray (05/28/24 OSMAK)
Atherosclerotic aorta
Ferrous Sulfate 325mg/tab, 1 Findings: Gyne wise
tab twice a day-HOLD Uterus is anteverted, normal in size measuring 5.5 x 3.5 x 5.3 cm. Definitive Plan: For possible
Gyne wise Mefenamic Acid 500mg/tab, 1 Myometrial echopattern is homogeneous. chemotherapy with concurrent
No profuse vaginal bleeding tab every 8hrs as needed for Endometrial lining is not thickened measuring 0.17 cm. Fluid is seen within the endometrium. pelvic EBRT with brachytherapy
No severe hypogastric pain pain Tranexamic Acid Cervix is enlarged measuring 5.7 x 5.1 x 5.4 cm. For referral to Anes service onc
500mg/tab, 1 tab every 8 hours A large heterogenous predominantly hypoechoic mass is seen encompassing the cervix measuring 5.4 x 4.7 x 4.8 cm. It with final OR schedule for
Menopause x 9 years as needed for vaginal bleeding shows increased vascularity upon Doppler interrogation. surgery
TVS UTZ (03/25/24 OSMAK) The right ovary is not visualized. For referral back to MRA servic
Soft flabby abdomen The left ovary is normal in size measuring 2.2 x 1.8 x 2.2 cm (volume of 4.5 cc) for clearance once electrolyte
Abdominal girth: 99cm No definite evidence of fluid seen in the posterior cul-de-sac. corrected
IMPRESSION Pad count qshift
- Normal-sized uterus with non-thickened fluid filled endometrium. Monitor vsq2
PE with Dr. Alfabeto (05/30)
- Enlarged cervix with heterogenous mass, worrisome for a neoplastic process. Tissue correlation is suggested. Monitor I&O q shift
Cervix is converted into
- Normal sized right ovary WOF: severe hypogastric pain,
8x8cm exophytic and friable
- Non visualized left ovary profuse vaginal bleeding
mass, extending to the
middle third of the vagina S/P CERVICAL PUNCH BIOPSY (04/24/24 OSMAK)
Pending:
anteriorly and on the right -- POORLY DIFFERENTIATED CARCINOMA WITH MUCINOUS FEATURES
[ ] Sputum GS CS (for send out)
Corpus small, no adnexal
amenable for send out to GA;
masses, bilateral parametria Ultrasound guided thoracentesis (06/06, OsMak) still unable to collect sample
nodular medially with
Scanning of the left hemithorax shows free fluid collection measuring approximately 665 ml. [ ] for repeat ABG – for send
clearance
Marking was done at the left mid to lower posterior chest wall. out, refused, with form
Asepsis/antisepsis, local anesthesia infiltration and thoracentesis performed by IM ROD.
Pad count: 0
After insertion of thoracentesis needle, tip was noted to be inside the hemithorax but with no output. Advanced directives: YES TO
Another attempt of thoracentesis was done; needle observed to enter hemithorax initially but no output was observed. ALL (06/02/2024)
Procedure was eventually deferred.
CBG monitoring
Date 0500H 1100H 1700H 2030H
06/1 - 117 124 108
0
6/9 252 174 132 129
6/8 120 173 117 120
6/7 127 125 100 132
6/6 235 137 133 125

6/5 190 
referred
to Endo
Gyne 6 Nulligravid BP 120/80 DAT with SAP CBC with PC
LOPEZ, QUEYZEE ROLDAN AUB- O, r/o M HR 64 IVF: PNSS 1L x KVO while on BT Date Hgb Hct WBC S L M E Plt
37 Blood transfusion of 3 units RR 20 (+) IFC
06/10
NYC pRBC for Anemia severe T 36.8 (+) O2 support s/p BT of 6.3 L 0.20 L 11.2 79 13 7 1 294
secondary to acute blood loss (+) cardiac monitor 2u pRBC
06/10/2024 PCOS I: 2430
06/09 5.0 L 0.16 L 8.4 74 16 8 2 329
3932261 Obese II O: 4000
O+/NR
Dr Santos/ Tungcul Go/Roque
Urinalysis
Reyes(TL)/Gauiran Papillary thyroid Ht:155cm
Tugado/Alzaga microcarcinoma, low risk Wt:87kg Date Sugar Protein WBC RBC Epithelial Bacteria Leukocyte
s/p total Thyroidectomy BMI: 36.1 (Obese II) 06/09 Neg Neg 0.4 0.2 5.5 1.5 Neg
(2010, PGH) 06/09 Neg +2 H 157.3 H 176.7 H 182.6 H 3666.7 H +1 H
Anemia severe secondary s/p BT of 3u pRBC 06/09 Neg +1 H 147.0 H 35.0 H 115.7 H 1735.9 H +2 H Anemia severe secondary to 1
to 1) acute blood loss 2) Diphenhydramine 50mg TIV 30 Chemistry: acute blood loss 2) Iron
Iron deficiency anemia mins prior to BT – given Date BUN Crea BUA Na K Cl AST ALT deficiency anemia
(-) dizziness Calcium gluconate 10% 10cc s/p BT of 3u PRBC
06/09 3.23 93.77 H 476.77 H 137.79 3.50 100.49 22.67 27.76
(-) generalized body SIVP post BT of 3u PRBC - given For BT of 1 more unit of pRBC
weakness Coagulation studies (c/o Ma’am Sarah)
(+) pallor Date PT % Activity INR APTT For repeat CBC 6hrs post BT of
(-) DOB/SOB 06/09 12.8 94.8 1.14 33.5 4th unit pRBC
Pale palpebral conjunctiva Thyroid function tests (06/10/24) TSR PBS result (done 06/09)
INCREASE levothyroxine from Date FT3 FT4 TSH
Papillary thyroid 112.5 mcg/day to 125 mcg/day 06/10 1.90 L 1.44 2.53
microcarcinoma, Low risk Ferritin (6/9/24 OSMAK): 18.00 L
(-) palpitations Ferrous Sulfate 325mg/tab, 1 Reticulocyte count (05/09 OSMAK): 4.8 H
(-) tremors tab twice a day Direct COOMBs Test (05/09 OSMAK): Negative Papillary thyroid
(-) chest pain Mefenamic Acid 500mg/tab, 1 Indirect COOMBs Test (05/09 OSMAK): Negative microcarcinoma, Low risk
(-) heat intolerance tab every 8hrs as needed for Pregnancy test (06/09/24): Negative Continue previous meds for
(-) sudden weight loss pain Fecal occult blood (06/09 OSMAK): Negative now
Tranexamic Acid 1g TIV every 8 12L ECG (6/9/24 OSMAK): Sinus rhythm, normal axis, LVH, no ischemia
Gyne wise hours as needed for vaginal Imaging IM Endo Notes (06/10)
No profuse vaginal bleeding bleeding Noted >10 year history of
Chest xray (06/09/24 OSMAK) No acute parenchymal opacities
No severe hypogastric pain reported no signs of recurrence
and with initial TG levels at low
LMP 5/29-6/8 normal values consider patient
PMP 5/4-10/2024 as low risk papillary thyroid
PMP 4/12-18/2024 microcarcinoma
Target: TSH level of 0.5-2.0
Abdomen flabby soft non- IU/ml
tender, (-) muscle guarding Increase levothyroxine from
(-) rebound tenderness 112.5 mcg/day to 125 mcg/day
Repeat serum TSH after 6 week
SE: Cervix pink, no mass, no May continue Calcium
erosions, minimal bleeding supplementation
per OS
Gyne wise
IE: Cervix 2x2 cm, smooth, PLAN: for anemia correction
closed, (-) CMT, uterus For TVS UTZ c/o OB sono
cannot be fully palpated due rotator-informed, for schedulin
to flabby abdomen, (-) AMT Pad count q shift
Complete bed rest without
RVE: free bilateral bathroom privilege
parametria WOF: severe hypogastric pain,
Pad count: 1 minimally profuse vaginal bleeding
soaked diaper
GYNE 5 G2P2 (2002) BP 120/80 DAT with SAP CBC with PC

LOMBOY, MICHELLE PANICAN Squamous cell carcinoma of HR 97 Heplock Date Hgb Hct WBC S L M E Plt
43 the cervix St IIB RR 20 (+) IFC 06/10
YC Blood transfusion of 2u pRBC T 36.7 (+) O2 support PRN 8.9 L 0.27 L 10.5 74 11 7 8 305
Stat CBC
for anemia severe secondary
06/10
06/09/2024 to malignancy I: 1614
s/p BT of 9.5 L 0.29 L 10.6 78 7 7 8 322
56374 Leiomyoma uteri O: 2050
2u pRBC
Dr Alfabeto/Tungcul Ovarian new growth, left
06/09 7.7 L 0.24 L 9.9 64 18 9 9 359
Go(TL)/Roque Reyes/Gauiran Ht:150cm
Tugado/Alzaga Urinary tract infection Wt:72.5kg O+/NR
Obese II BMI: 32.2 (Obese II) Urinalysis Anemia severe secondary to
Date Sugar Protein WBC RBC Epithelial Bacteria Leukocyte malignancy
S/p Cervical punch biopsy Anemia severe secondary Ongoing BT of 3rd u pRBC 06/09 Neg +2 H 49.9 H 3568.3 H 28.5 303.0 H +2 H For anemia correction
(01/12/2024) to malignancy s/p BT of 2u PRBC Chemistry: Ongoing BT of 3rd unit pRBC (TE
(-) dizziness Diphenhydramine 50mg TIV 30 Date BUN Crea BUA Na K Cl AST ALT 1000H)
(-) generalized body mins prior to BT- given 424.78 H 136.02 3.58 105.15 12.62 5.75 For repeat CBC 6hrs post BT of
06/09 2.60 51.06
weakness Calcium gluconate 10% 10cc 3rd unit pRBC (1600H)
(-) pallor SIVP post BT of 3u PRBC Coagulation studies
(-) DOB/SOB Date PT % Activity INR APTT Urinary tract infection
Slightly pale palpebral 06/09 12.3 98.4 1.09 30.3 Increased oral fluid intake
conjunctiva Ferritin (6/9/24 OSMAK): 52.51 TSR urine CS c/o GA (done
Ceftriaxone 2g TIV OD (D1) Pregnancy test (06/09/24): Negative 06/10)
Urinary tract infection 12L ECG (6/9/24 OSMAK): Non-specific STT wave changes on lead III and V1
(-) dysuria Tumor markers (04/12/24) Gyne wise
(-) hematuria CA-12-5: 619.70 U/L H PLAN: for anemia correction
(-) increased urinary CA-19-9: 14.67 U/mL Definitive plan: for radiotherap
frequency Imaging LOA still for approval
(-) fever Ferrous Sulfate 325mg/tab, 1 Chest xray (06/09/24 OSMAK) Cardiomegaly Monitor 4h, I&O q shift
tab twice a day Findings: Complete bed rest for now
Paracetamol + tramadol tab, 1 The liver is normal in size with slightly increased parenchymal Pad counting q shift
Gyne wise tab every 8hrs as needed for echogenicity. WOF: severe hypogastric pain,
(+) profuse vaginal bleeding pain There are no focal mass lesions noted. profuse vaginal bleeding
(-) severe hypogastric pain Tranexamic Acid 1g TIV every 8 The intrahepatic ducts are not dilated.
hours for 24 hours then as The gallbladder is normal in size measuring 5.23 x 2.25 cm.
LMP: 05/04-present needed for vaginal bleeding Its wall is not thickened. No pericholecystic fluid seen.
PMP: April 23-26 There are no intraluminal
PMP: Feb 24-26 echoes or focal lesions noted.
PMP: Jan 25-29 The common duct is not dilated to the extent visualized, measuring 0.5
PMP: Dec 1st week (lasted cm.
for 3 weeks) The visualized pancreas and spleen are normal in size and echotexture.
PMP: Nov 1st-3rd week There are no focal lesions appreciated.
PMP: Oct 4-6 Both kidneys are normal in size with smooth and regular contour.
PMP: Sep 5-8 The cortico-medullary pattern in both sides is intact.
The right kidney measures 10.8 x 6.1 × 4.3 cm with cortical thickness of 0.8
Soft flabby abdomen cm.
The left kidney measures 11 x 4.6 x 4.4 cm with cortical thickness of 0.8
SE: Cervix 5x5 cm, nodular, cm.
scanty bleeding per os There is no evidence of hydronephrosis, lithiasis or mass noted in both
Whole Abdomen UTZ (03/06/24)
IE: Cervix 5x5 cm, friable kidneys.
Involvement of The urinary bladder is adequately distended.
middle 1/3 anteriorly Its wall is not thickened.
upper 1/3 posterior of the There are no intraluminal
vaginal canal echoes or focal mass seen.
Pre-void: 195 ml
RVE: bilateral parametria Post-void: Scant
nodular but free Incidental note of a heterogeneous focus in the cervical region, which
apparently extends into the lower uterine segment. The endometrium has
Pad count: 2 diapers (1 normal thickness with endometrial fluid and small hyperechoic focus
mildly soaked, 1 fully projecting within.
soaked)
Impression:
Mild fatty liver
Unremarkable sonogram of the gallbladder, visualized pancreas, spleen,
both kidneys and urinary bladder.
Heterogeneous focus in the cervical and lower uterine segment; likely the
patient’s known pathology.
Endometrial fluid and probable endometrial polyp. Suggest dedicated
study for further evaluation.
WAB CT Scan (03/13/2024, Makati Life Medical Center) Findings
Liver: Normal size and attenuation. Contour is smooth and no focal lesions
are dernonstrated. No dilated intrahepatic bile ducts.
Gallbladder: Normal size and wall thickness. No lithiasis is demonstrated.
Pancreas, spleen and adrenal glands: Unremarkable with no evident focal
lesions.
Stomach and bowel loops: Lack of oral and rectal contrast precludes
optimal evaluation. Non-obstructive bowel pattern is seen.
Kidneys and ureters: Normal in size and confiquration. No evidence of
lithiasis or hydronephrosis. The ureters are not dilated.
Urinary bladder: Well distended and unremarkable.
Uterus and adnexa: Poorly defined mass in the cervix with apparent
extension to the lower uterine endometrial cavity fluid is seen. A
hypoenhancing mass is also noted in the right lateral uterine wall
measuring 3.2 x 3.9 cm (AP/T). There is a multiseptated cystic mass in the
left adnexal region measuring 4.1 x 2.7 x 5.6 cm (AP/TICC, likely ovarian in
origin.
Ascites, mesenteric thickening, or enlarged lymph nodes: None.
Vascular, osseous, and soft tissue structures: Tiny sclerotic focus in right
femoral head, likely a bone island.
Impression:
Poorly defined mass in the cervix with apparent extension to the lower
uterine segment and moderate endometrial cavity fluid is seen. This is
consistent with the clinically known cervical malignancy.
Hypoenhancing mass in the right lateral uterine wall, may represent
uterine myoma
Multiseptated cystic mass in the left adnexal region, likely ovarian in
origin. Correlate with transvaginal ultrasound for further evaluation.
Tiny sclerotic focus in right femoral head, likely bone island
Uterus 4.5 x 3.93 x 3.85
Endometrium: 0.69
homogenous, hypoechoic, midline echo well defined, regular
endomyometrial junction
Cervix 2.2 x 1.95 x 2.69
RO 2.54 x 1.39 x 1.71
TVS UTZ c/o OB SONO (Jan 12, 2024)
LO 1.5 x 1.3 x 1.7
IMPRESSION:
Normal retroverted uterus
Intact endometrium
Normal ovaries
Cervical punch biopsy (01/12/24 OSMAK): SQUAMOUS CELL CARCINOMA, NOT OTHERWISE SPECIFIED (NOS).
PERIPHERALS
SARI 3 BED 3 Nulligravid BPR 140-150/80-90 Renal diet CBC with PC
LIPARDO, MARY GRACE AUB-A,M,O BP 150/90 IVF: PNSS 1L x KVO while on BT Date Hgb Hct WBC S L M E Plt
CASTA Blood Transfusion of 1 unit pRBC HR: 65 (+) cardiac monitor
06/10
38 for Anemia severe secondary to 1) RR: 20 (+) O2 support at 4LPM via nasal *IFC refused
s/p BT
NYC malignancy 2) chronic blood loss T: 36.8 cannula 7.4 L 0.21 L 10.8 88 6 5 1 268 With 1u pRBC c/o Ma’am
of 2u
ESRD sec to HTN NSS vs DKD Type O2: 99
pRBC
3890682 2 Diabetes Mellitus, controlled
06/08/2024 Hypertension Stage II, controlled I: 1640 06/08 4.9 L 0.14 L 8.5 84 10 5 1 343
Dr. Odevilas/ Tungcul, Proliferative diabetic retinopathy, O: 0 A+/NR
Ballesteros, De Paz (TL)/ De both eyes Vitreous hemorrhage, Urinalysis
Guia, Pesigan/ Jasarino, Vito left eye Ht 5’2’’ Date Sugar Protein WBC RBC Epithelial Bacteria
t/c Community Acquired Wt 84kg
Pneumonia BMI 33.8 Chemistry:
s/p Panretinal photocoagulation, Date BUN Crea Na K Cl AST ALT Anemia severe secondary to 1) malignancy 2) chronic blood loss
right eye Anemia severe secondary to s/p BT of 2 unit pRBC 06/1 6.45 s/p BT of 2u pRBC
1) malignancy 2) chronic Diphenhydramine 50mg IV 30 0 H Give Furosemide 40mg IV after each aliquot with BP precaution
blood loss minutes prior to BT – given 06/1 6.78
(+) slight pallor Paracetamol 300mg IV 30 0 H
(+) slightly pale palpebral minutes prior to BT – given
06/0 2,184.72 7.17 97.04 L 9.17 8.25
conjunctiva Calcium gluconate 10% 10cc 37.79 H 129.33 L
8 H H
(-) easy fatiguability SIVP post BT of 3u PRBC
05/1
(-) dizziness Furosemide 40mg IV after each 10.52 H 739.08 H
8
aliquot with BP precaution
05/0
22.23 H 1292.64 H
9
Reticulocyte count (06/08/24): 2.3% (H)
12L ECG (06/08/24): NSR, tall T-waves V2-V4 ESRD sec to HTN NSS vs DKD Type 2 DM, controlled
COVID rapid antigen test (06/09/2024): Negative IM Notes (06/10)
ESRD sec to HTN NSS vs DKD Hba1c (6/9/24): 4.11% Facilitate dialysis as ordered
(+) decreased urine output FeSO4 325mg/tab 1 tablet once Hepatitis profile (6/8/24) Maintain heplock
(-) nausea daily HbsAg 0.41 - NONREACTIVE Standby Nicardipine drip: 20 mg Nicardipine in 80 cc PNSS to start at
(-) easy bruising Ferrous + Folate tab 1 tablet Anti-HCV 0.09 - NONREACTIVE 10 cc/hr +/- 5 cc/hr for target BP < 140/90
(-) headache once daily Anti-HBc IgG 1.69 - NONREACTIVE CBG TID ACHS
(-) fatigue EPO 4,000 3x a week post HD
Anti-HBs 83.06 - REACTIVE
(-) drowsiness Sevelamer 800mg/tab, 1 tab q8
Sodium bicarbonate 650mg/tab IM Nephro (06/10)
1 tab 3x/day Imaging Noted latest Hgb
CXR (6/9/24, OSMAK) Low lung volume with bronchovascular crowding. Cannot totally exclude pulmonary congestion or beginning Please deck to HD today then 2x/week MWF UF 4L BUR 4H Qb 250
06/11 pneumonia. Qd 500 non heparinized 50 cc glulisine every 30 mins regular cath,
1600H 180/80 -> Due Probable cardiomegaly right
Metoprolol KUB UTZ (05/13/24 Findings: For BT while on HD suggest to secure 1-2 units pRBC for BT while on
1730H 180/80 -> Clonidine -> OSMAK) Both kidneys are normal in size with smooth and regular contour. HD as fastdrip
180/80 -> Clonidine -> 180/80 The cortico-medullary pattern in both sides is intact. Please deck to HD once with confirmed blood products
-> Amlodipine -> 150/90 The right kidney measures 9 x 3.2 x 3.9 cm with cortical thickness of 1 cm. Discontinue K correction once on HD
The left kidney measures 9.1 x 3.7 x 3.7 cm with cortical thickness of 1 cm.
There is no evidence of hydronephrosis, lithiasis or mass noted in both kidneys. Type 2 DM, controlled
The urinary bladder is nondistended. For CBG monitoring and control
Insulin glulisine sliding scale IMPRESSION: For CBG TIDACHS
Type 2 DM, controlled 180-220 2u Unremarkable ultrasound of both kidneys IM Endo notes (06/10)
(-) polyphagia 221-260 4u Nondistended urinary bladder Thank you for this referral
(-) polydipsia 261-300 6u TVS UTZ (05/10/24, Findings: Diagnostics: FBS
(-) polyuria >300 8u OsMak) Uterus is anteverted and enlarged measuring 9.1 x 7.6 x 7.5 cm (volume of 272 mL). Therapeutics
Myometrial echopattern is homogeneous. Insulin glulisine sliding scale
No focal mass is seen. 180-220 2u
Amlodipine 10mg/tab 1 tab OD Endometrial lining is thickened and heterogeneous measuring 2.1 cm. 221-260 4u
Hypertension St. II, controlled Metoprolol 50mg/tab 1 tab BID The right ovary is normal in size measuring 3.0 x 1.9 x 2.6 cm (volume of 7.8 mL). 261-300 6u
(-) BOV The left ovary is likewise normal in size measuring 2.6 x 2.1 x 2.0 cm (volume of 6.0 mL). >300 8u
(-) headache No adnexal mass is noted.
(-) dizziness 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.
(-) chest pain Minimal fluid is seen in the posterior cul-de-sac. HTN St. II, controlled
(-) DOB/SOB Impression: For BP monitoring and control
(-) vomiting Enlarged anteverted uterus with thickened and heterogeneous endometrium. Tissue correlation is suggested.
Open cervix with endocervical fluid IM Notes (06/09/24)
GICS as follows q2 hours x 6 Minimal posterior cul-de-sac fluid Tx:
Multiple electrolyte cycles (completed 06/10 0200H) Unremarkable ultrasound of the ovaries Amlodipine 10mg/tab 1 tab OD
imbalance (Hyponatremia, -Glucose D50-50 1 vial TIV + Chest Xray (05/09, Cardiomegaly Metoprolol 50mg/tab 1 tab BID
hyperkalemia, Insulin HR 10 units TIV OsMak)
hypochloremia) secondary to -Calcium gluconate 10%, 10 ml 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 Multiple electrolyte imbalance (Hyponatremia, hyperkalemia,
ESRD as slow IV push Megason) and heterogeneous. Endometrial stripe is thickened measuring 2.1 cm. Cervix is normal with intact canal hypochloremia) secondary to ESRD
(-) chest pain -Salbutamol MDI, 2 puffs now measuring 3.2 x 1.9 x 2.1 cm. IM Nephro (06/09
(-) palpitations Calcium polysterene sulfonate 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). Tx:
(-) tremors 15g/sachet, dissolve 1 sachet in Multiple subcentimeter peripherally distributed cystic foci are seen in both ovaries. 1 - GICS as ordered to complete for 6 cycles then repeat
1/2 glass water now then every The posterior cul-de-sac is intact. 2 – Calcium polysterene sulfonate 15g/sachet, dissolve 1 sachet in
8 hrs IMPRESSION: 1/2 glass water now then every 8 hrs
Enlarged and bulky, anteverted uterus with coarsened and heterogeneous 3 – Pantoprazole 40mg/tab 1 tab OD
No meds for now myometrium and thickened endometrium. Primary consideration is diffuse uterine adenomyosis; rule out
endometrial hyperplasia. Tissue correlation is recommended for further evaluation.
t/c Community Acquired Normal sized ovaries with polycystic features bilaterally. Please correlate with clinical and laboratory findings. t/c Community Acquired Pneumonia
Pneumonia CBG monitoring referred to IM-Pulmo c/o Dr Capalaran-awaiting notes
(-) DOB/SOB
Date 0500H 1400H 1720H 2100H
(-) cough No meds for now Proliferative diabetic retinopathy, both eyes Vitreous
(-) desaturation 06/1 104 120 151 153 hemorrhage, left eye s/p Panretinal photocoagulation, right eye
(-) fever 0 For referral back to Ophtha service c/o Dr Lee-awaiting notes
6/9 124 136 104 150
Proliferative diabetic Ophtha Notes from previous admission (05/11)
retinopathy, both eyes Ideally for OFE, patient prefers to undergo full OFE once more stable
Vitreous hemorrhage, left eye or discharged
s/p Panretinal Tranexamic Acid 1g TIV every 8 Scheduled fo ophtha consult with retina clinic on Thursday, May
photocoagulation, right eye hours for 24 hours then 500mg 1 16,2024, confirmed with retina fellow (Dr. Coranez)
(-) sudden vision loss tab every 8 hours as needed for Signing out of this case
(-) eye redness vaginal bleeding
(-) floaters SHIFT Mefenamic acid to Gyne wise
Paracetamol + Tramadol For anemia correction
Visual acuity: 20/20 both eyes 325mg/37.5mg/tab 1 tab every 8 Referred back to Nephro regarding Tranexamic acid renal dosing (Dr.
Intact EOMs hours as needed for pain Manayon)
Gyne wise ANES (5/18)

(-) hypogastric pain Patient seen and examined
(-) vaginal bleeding History and PE done
Ancillaries noted
Nulligravid Anesthesia plans, risks, and complications explained and fully
LMP: May 3-present understood by patient and husband
PMP: March last week to April Still for anemia and hyperkalemia correction
second week Respectfully suggesting to do endometrial biopsy as an elective case
PMP: February 1st week to fully optimize the patient
PMP: Nov 6-present Patient have signed advanced directives of DO NOT INTUBATE but
(4overnight pads, moderately upon assessment, patient is with increased risk of desaturation thus
soaked) is resolved by intubating patient, with DNI signed, then we cannot
PMP: Sept 20, 2023- October help the patient
3rd week Suggesting to undergo HD prior to procedure
PMP: third week of august Refer back to APEC as scheduled
PMP: 3rd week of July 2023
Abdomen flabby, no
tenderness on light/deep Advanced directives: YES TO ALL
palpation on all quadrants, no
muscle guarding Contact number of relative: 09055692214
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: 0
Bed 1 IW G6P5(5015) BPR 120-140/80-90 Light meals CBC

PILAPIL, MILAGROS Endometrial carcinoma, high BP 130/80 IVF: PNSS 1L x KVO while on BT Date Hgb Hct WBC S L M E Plt
BALMORI grade, t/c serous carcinoma t/c HR 78 IVF: PNSS 1L x 80cc/hour for 12 06/09
79 Stage 1B RR 20 hours prior administration of s/p 3u 11.7 0.35 19.1 88 7 4 1 234
YC Menopause for 29 years T 37.0 contrast and continuing 12 hours pRBC *advised to secure blood products, green form given to relative of
Blood Transfusion of 3 units PRBC after procedure 06/08 5.1 L 0.16 L 22.5 H 83 H 13 4 0 242 patient to secure blood outside
215005 for Anemia very severe secondary I: 1100 (+) O2 support via nasal cannula *Patient supposedly for transfer to IM isolation ward however as per
O+/NR
06/08/2024 to 1) malignancy 2) acute blood O:1200 at 4LPM IM service patient still to secure official sputum AFB result, patient
Urinalysis
Dr. Santos/ Tungcul/ loss, corrected (+) IFC was appraised for possible THOC if no vacancy at isolation ward
Date Sugar Protein WBC RBC Epithelial Bacteria
Ballesteros, De Paz/ Roque Acute kidney injury secondary to Ht: 5’3 (+) cardiac monitor
(TL)/ Reyes*/ De Guia, 1) hypoperfusion from acute blood Wt: 80 kg 06/08 3+ Trace 86.3 H 0.5 28.5 5906.6 H
Pesigan/ Jasarino, Vito loss; 2) infection from complicated BMI: 31.2 (obese II) Chemistry:
UTI; 3) Diabetic nephropathy Date BUN Crea BUA HbA1c Na K Cl AST ALT
Complicated UTI Anemia very severe 06/1 4.17 Anemia very severe secondary to 1) malignancy 2) acute blood loss,
Hyponatremia secondary to poor secondary to 1) malignancy 2) s/p BT of 3 units pRBC 1 corrected
nutrition acute blood loss, corrected Diphenhydramine 50mg TIV 30 06/1 130.45 L 3.84 L s/p BT of 3u pRBC
Hyperkalemia secondary to poor (-) pallor mins prior to BT – given 1
nutrition, corrected (-) pale palpebral conjunctivae Calcium gluconate 10% 10cc 06/0 9.18 H 128.32 L 5.68 97.70 19.24 10.77 Acute kidney injury secondary to 1) hypoperfusion from acute
Type II Diabetes Mellitus, poorly (-) generalized weakness SIVP post BT of 3u PRBC-given 5.10 128.19 H 564.20 H blood loss, 2) infection from complicated UTI 3) Diabetic
8 H
controlled (-) dizziness Lipid Profile nephropathy
Hypertension, controlled VLDL Nephro notes (06/10)
Date TC TG HDL LDL
Dyslipidemia Referred to Dr. Vega for AKI complicated UTI
r/o PTB 3.4 1.1 2.03 0.56 Awaiting urine CS
06/10 1.24
Obese II Acute kidney injury 5 9 Awaiting repeat Na, K - 12 mn
secondary to 1) Ideally for ABG
S/P Endometrial biopsy (HIGH hypoperfusion from acute Coagulation studies Noted plans for contrat studies
GRADE CARCINOMA, FAVORS blood loss, 2) infection from No meds for now Date PT % Activity INR APTT RCIN 16 score 4 anemia 3 DM 3 Contrast 2 CR 4
SEROUS CARCINOMA, 2023, complicated UTI 3) Diabetic 05/09 12.3 98.4 1.09 25.2 Risk of 26%
OSMAK) nephropathy 05/30 15.2 H 75.6 1.37 H 39.4 Ris of 1.09%
(-) decreased urine output BUN, Crea 2 days after contrast studies
(-) decreased sensorium ERPR (OsMak, July 14, 2023) Continue ceftriaxone 2 g TIV once a day
ER – focal strong (+) staining PNSS 1 L x 60 cc/hr
PR – focal strong (+) staining Hyponatremia secondary to poor nutrition
Hyponatremia secondary to Hyperkalemia secondary to poor nutrition, corrected
Immunohistochem (Hi-Pre, July 17, 2023)
poor nutrition For electrolyte correction
Hyperkalemia secondary to Calcium polystyrene 1 sachet p16 Positive, strong, diffuse IM Nephro (6/8/24)
poor nutrition, corrected every 8 hours for 3 doses p53 Aberrant/mutational type (>80% nuclear strong staining) Tx: Calcium polystyrene 1 sachet every 8 hours for 3 doses
(+) generalized weakness (completed 6/9 1800H) Tumor Markers (06/27/23)
(-) diarrhea/vomiting CA 125: 7.38 Complicated UTI
(-) seizure CA 19-9: 1.20 For completion of antibiotics
(-) decreased sensorium 12L ECG (6/8): sinus arrythmia TSR urine CS (sent out to GA – 6/8)
Imaging
Complicated UTI Hypertension, controlled; Dyslipidemia
CXR Apicolordotic view (06/08/24) Reference was made to the chest radiograph done on the same day (11:37 AM).
(-) hypogastric pain Cardio Notes (06/10)
(-) dysuria Ceftriaxone 2g TIV (-) ANST OD Reticular opacities are seen in the right upper lung. Referred to Dr. Cuenca for BP control
(-) hematuria (Day 2) IMPRESSION: Continue the ff:
Consider PTB of undetermined activity, right upper lung. Correlate with pertinent parameters. 1. Amlodipine 10 mg/tab 1 tab OD
Hypertension, controlled; CXR (06/08/2024) Suspicious opacities in the right upper lung are seen. 2. Carvedilol 25 mg/tab 1/2 tab 2 times a day
Dyslipidemia Pulmonary vascular markings are within normal limits. Type II Diabetes Mellitus, poorly controlled
(-) chest pain Carvedilol 25mg/tab 1tab BID For CBG monitoring and control
The heart is magnified.
(-) headache Amlodipine 10mg/tab OD For lipid profile once anemia corrected
(-) dizziness Rosuvastatin 20mg 1 tab once a The tortuous aorta is calcified.
(-) nape pain day at bedtime Both hemidiaphragms and costophrenic angles are intact. Endo Notes (06/10)
Osteophytes are seen lining the margins of the visualized spine. Referred to Dr. Amba for uncontrolled type 2 DMIdeally for lipid
Type II Diabetes Mellitus, IMPRESSION: profile
poorly controlled Linagliptin 5mg/tab 1 tab OD Suggest apicolordotic view Insulin glargine 26u SC at 8 pm by dinner
(-) polydipsia Insulin Glargine 20u at night Insulin glulisine premeals 6-10-6 units
Tortuous and atheromatous aorta
(-) polyuria Insulin Glulisine pre-meals (6u Insulun glulisine sliding scale as ordered
Degenerative osseous changes of the visualized spine
(-) polyphagia prebreakfast, 6u prelunch, 6u Linagliptin 5 mg 1 tab once a day
See table for CBG monitoring predinner) TVS UTZ (03/07/2023) The uterus is anteverted with smooth contour and heterogeneous echopattern measuring 7.4 x 4.5 Rosuvastatin 20 mg 1 tab at bedtime
Insulin Glulisine sliding scale: x 3.6 cm. The cervix measures 2.1 x 2.5 x 2.7 cm with homogeneous stroma and distinct CBG TID ACHS
181-220: 2u SC endocervical canal. r/o PTB
221-260: 4u SC Within the endometrial cavity is a heterogeneous mass measuring 4.0 x 3.4 x 29 cm (volume: 20.9 Pulmo Notes (06/10)
261-300: 6u SC Referred to Dr. Orion
cc), with >50% myometrial invasion. The caudal tip of the mass is at the level of the internal cervical
>300: 8u SC For sputum AFB x 2
r/o PTB os and is 2.0 cm away from the external cervical os (dist. OCO). The endometrial midline echo is not Noted clearance for transfer to infectious ward
(-) history of previous PTB defined The thinnest myometriumi isat the anterior midcorpus measuring 0.2 cm. The endometrial- N95 at all time
treatment myometrial j junction is indistinct. Airborne precaution
(-) cough, night sweats NAC 600mg/tab 1 tab BID for 4 The right ovary measures 2.4 x 1.6 x 2.0 cm (volume: 3.9 cc). Within the right ovary is a unilocular Will not treat as PTB if sputum AFB negative x 2
(-) DOB/SOB doses prior to study anechoic cyst measuring 1.3 x 1.2 x 1.6 cm (volume: 1.3 cc). There are no solid areas or papillary Please do sputum induction
NAC 600mg/tab 2 tabs PO prior excrescences seen within. The capsule measures 0.1 cm.
to and after the study (if NPO, Referred to IPC-cleared for transfer to IW
The left ovary measures 1.1 x 1.1 x 1.0 cm (volume: 0.7 cc)
may use IV NAC) Endorsed to Dr. Viernes/Almirol
Gyne Wise There are no adnexal masses seen. Please transfer to IW
(+) vaginal bleeding The cul-de-sac is smooth with no free fluid.
(-) severe hypogastric pain IMPRESSION: Gyne Wise
(-) bladder/bowel movement Ferrous Sulfate 325mg/tab, 1 tab ENDOMETRIAL MASS CONSIDER MALIGNANCY, WITH >50% MYOMETRIAL INVASION For metastatic workup (chest CT scan/WAB CT scan with IVC)
changes twice a day RIGHT OVARIAN CYST CONSIDER SIMPLE CYST For referral back to Gyne Onco (June 11, 2024)
Paracetamol + Tramadol ATROPHIC LEFT OVARY
G6P5 (5015) 325/37.5 mg/tab, 1 tab every Previous Gyne Onco Plans: FOR NEOADJUVANT RADIATION then for
Menopause: 1995 8hrs as needed for pain re-assessment c/o Gyne Onco thereafter
ENDOMETRIAL BIOPSY (06/12/2023 OSMAK): HIGH GRADE CARCINOMA, FAVORS SEROUS CARCINOMA WOF: profuse vaginal bleeding, severe hypogastric pain, hypotension,
Previous Gyne PE (c/o Dr. tachycardia, decreased sensorium
Santos) CBG monitoring
IE: Cervix dilated as thin Date 0500H 1100H 1400H 1720H 2100H 2300J Pending:
smooth rim [ ] Urine CS – sent out to GA (06/08)
(+) Fleshy mass protruding, 06/10 125 124 62 -> D5050 184 [ ] For Chest/WAB CT scan with IVC (on June 19, 2024 c/o Dr.
outgrowth lesion per os 6/9 252  insulin 152 203 Insulin 6u 110 Capuchino)
Uterus enlarged to 10 weeks 12u [ ] For sputum AFB x 2
size; no adnexal mass nor 6/8 400  300cc  493  referred to 407  insulin 20u [ ] ABG- pt amenable for send out
tenderness [ ] sputum AFB x 2
496 Endo
RVE: Shortened bilateral [ ] BUN, Crea 2 days post contrast
parametria, closed to the Advanced directives: YES TO ALL
pelvic wall
PE at the ER (6/8)
IE: (+) Fleshy mass protruding,
outgrowth lesion per os,
uterus cannot be palpated
enlarged abdomen
Pad counting: 1 minimally

soaked
REFERRALS
704 G3P3 (3003) BP 110/70 TCR of 1000kcal DAT CBC
PICONES, JOSEL PASCUAL Cervical Carcinoma St IIB HR 210 divided into 3 meals and 2 Date Hgb Hct WBC S L M E Plt
32 Bacterial Vaginosis, RR 20 snacks with Ensure 6 06/08 10.2 L 0.31 L 18.5 H 92 3 5 596 H
YC resoleved T 36.5 scoops in 200ml water 05/25 13.3 0.39 14.5 91 4 4 1 515 H
Blood transfusion of 4 IVF B fluid 1L x 24 hrs 05/22 10.5 L 0.31 L 16.5 H 93 H 5L 2 581 H
units pRBC for anemia I: 2649 Fracture, closed, comminuted, displaced,
61564 05/19 8.7 L 0.26 L 16.0 H 94 H 2L 4 603 H
moderate secondary to O: 2500 subtrochanteric femur, left
Date Admitted: 05/10/2024 05/15 9.2 L 0.28 L 10.4 92 H 6L 2 529 H
malignancy, corrected Superolateral dislocation, patella, left
Date Referred: 05/24/2024 05/13 8.9 L 0.26 L 11.2 90 H 3 6 1L 447
Fracture, closed, Ht: 47 kg Still for reduction possible open application of
Dr. Santos, Odevilas/Tungcul, comminuted, displaced, Wt: 150 cm 05/10 11.3 L 0.34 L 10.5 90 H 4L 5 1L 513 H intramedullary nail, left femur.
de Paz, Ballesteros/ Reyes (TL)/ subtrochanteric femur, BMI: 20 kg/m2 O+/NR
Tugado, Gallano/ Alzaga, Vito left Urinalysis Surgery Notes (06/10/24)
Superolateral dislocation, Date Sugar Protein WBC RBC Epithelial Bacteria DAT, with SAP
patella, left Fracture, closed, Paracetamol 500mg tab 1 06/08 NEG 2+ 245.4 13.1 4.1 71.5 Continue IV fluids
comminuted, displaced, tab every 6 hours 05/23 NEG NEG 2-4 3-5 FEW FEW Provide adequate analgesia
s/p Radiotherapy x 28 subtrochanteric femur, left Tramadol 50mg TIV every 05/19 NEG Trace 8-10 H 2-4 FEW FEW For MDP meeting on 06/14/24 10 am via zoom
fraction Superolateral dislocation, 8 hours 05/13 NEG Trace 1-3 0-2 FEW FEW Maintain four boot
s/p Chemotherapy x 4 patella, left Celecoxib 200mg cap 1 Coagulation studies Gyne and palliative notes highly appreciated
cycles (Dec 18 2023, Jan (-) DOB/ SOB cap BID Date PT % Act INR APTT
14 2024) (-) fever, last episode: calcium carbonate + Vit Ortho Notes (06/07/24)
05/25 13.4 90.1 1.2 39.8
s/p Cervical punch biopsy 1725H 06/01, 39.0 -> D3 200mg/tab, 2 tabs OD Dr. Lim updated
05/22 14.0 84/8 1.26 H 40.2
(09/25/2023) Paracetamol 1 g TIV -> 37.3 Morphine 10mg/tab,1 tab Palliative notes highly appreciated please carry
(+) foam boot traction in 05/10 12.9 94.0 1.15 41.3
every 8 hours round the Chemistry out
Previous Emergency Low place, left clock. Rescue dose of Referred back to Gyne re future plans and current
Date BUN Crea Mg Albumin Na K AST ALT HbA1c CL iCa Total Ca
Transverse Cesarean Morphine 10mg/tab, 1/2 status of patient
06/03 32.42 0.65 L 27.94 L 131.06 L 4.04 95.42 L 1.38 2.34
Section I for abruptio tab as needed for patient. Noted pre family conference from Dr Lim updated
05/30 132.83
placenta over GETA Paracetamol 1g TIV every TCR of 1000kcal DAT divided into 3 meals and 2
(5/22/23) 4 hours round the clock 05/25 4.36 snacks with Ensure 6 scoops in 200ml water
Zolendronic acid 4mg by 05/22 31.98 L 0.78 31.52 131.43 L 4.33 24.45 26.60 5.16% CHON 55g
SIVPx 15mm 3x/week- 05/15 44.98 L 131.21 L 4.20 CHO 100g
HOLD (06/03/24) 05/14 0.59 L Fat 459g
05/13 5.11 37.86 L 128.55 L 4.67 Continue IVF B fluids 1L x OD
05/10 5.98 44.23 L 33.44 L 129.04 L 5.37 H 55.98 H 44.92 H Food recall c/o relative
Vaginal Discharge GS (05/24/24): SMEAR SHOWS PRESENCE OF GRAM NEGATIVE COCCOBACILLI, MODERATE LEUKOCYTES AND EPITHELIAL CELLS
Vaginal Discharge KOH (05/24/24): NEGATIVE Anesthesia Notes (05/30/24)
ECG (05/24): Normal sinus rhythm Thank you for this referral
Imaging Patient seen and examined
Chest xray (06/07, Osmak) No significant chest findings History and PE done
Bone Imaging (MMC, 5/7/24) Clinical Data: Patient was diagnosed with poorly differentiated carcinoma of the cervix (2023) and underwent Labs noted
chemotherapy and radiotherapy. (+) left femoral fracture. Anesthesia plans, risk and complications explained
Technical Report: Whole body scans in the anterior and posterior views were obtained 3 hours after injection of 466 to and fully understood by the patient
MBq (12.6 mCi) of Tc-99m MDP. Dual intensity images were produced and SPECT was performed from the head to NPO 8 hours prior to wheel-in
mid-thigh. IVF: PNSS 1L x KVO rate to hook prior to OR
Scintigraphic Findings: Medications:
There is satisfactory skeletal labeling. Both kidneys are visualized. 1. Omeprazole 40mg IV once a day
Increased tracer accumulation in the proximal third of the left femur, corresponds to the known fracture. 2. Paracetamol 1g IV 1 hour prior to OR
Foci of increased tracer uptake are seen in the following: 3. Tramadol 50mg + 9ml PNSS via slow IV push
- anterior segment of the 8th right rib every 8 hours as needed for moderate and severe
- posterior segment of the 7th left rib pain.
- T6 and T11 vertebra Secure 2nd IV line (g18 or g 20) on the
- sacrum contralateral arm then shift to helpock
- left ilium Secure 2 units Prbc properly typed and
The rest of the visualized skeletal structures show symmetrical and physiologic tracer distribution. crossmatched prior to OR
Impression: For serum Na correction (>= 135mmol/L –
Increased osteoblastic activity in the areas described above is consistent with bone metastases. 145mmol) prior to OR
A pathologic fracture in the left femur is a consideration. Will refer this case to our service consultant
Chest CT scan with IVF (MMC, 5/7/24) Lungs and large airways: Few subcentimeter non-calcified pulmonary and subpleural nodules in the lateral segment of Check CBG and VS prior to wheel-in. Inform at
the right middle lobe, and superior segment of the right lower lobe, measuring none larger than 3 mm wide. local1416.
- Subcentimeter calcified pulmonary nodule in the superior segment of the left lower lobe is identifed measuring 2 mm Suggest sodium correction prior to OR, but if
wide benefits outhweight the risk may proceed with
- Small air cyst in the superior segment of the right lower lobe measuring 3 mm wide. contemplated rooms
Pleura: Pleural thickening in the left lower lobe
Heart and pericardium: Heart size is normal No pericardial effusion. IDS Notes (05/24/24)
Mediastinum and hila: No enlarged lymph nodes. Noted urinalysis results, no symtptoms of dysuria,
Chest wall and lower neck: Unremarkable. hematuria, flank pain
Vessel: Unremarkable. Fever may be attribute to known malignancy
Bones: Lytic lesions with soft tissue component in the vertebral bodies of T11 and T12, posterior aspects of the left 4 th, process
Anemia moderate 7th and 10th ribs, and lateral aspect of the right 8th rib IDS wise will not treat as CUTI
secondary to malignancy, s/p BT of 4u pRBC - Sclerotic foci in the vertebral bodies of T6 and T7 are seen. Respectfully signing out of this case.
corrected - Schmorl’s node in the inferior endplate of T11.
(-) pallor Others: The visualized liver parenchyma appears heterogeneous with vaguely-defined hypodensities. Anemia moderate secondary to malignancy,
(-) DOB/SOB IMPRESSION: corrected
Pink palpebral conjunctiva I. Few non-specific, non-calcified pulmonary and subpleural nodules in the right middle and right lower lobes. Interval s/p BT of 4u pRBC
follow-up is suggested to monitor stability or interval change.
Bacterial Vaginosis, 2. Subcentimeter calcified granuloma in the left lower lobe. Bacterial Vaginosis, resolved
resolved Metronidazole 500mg tab 3. Small air cyst in the right lower lobe. For completion of antibiotics
(-) fever 1 tab every 12 hours x 7 4. Lytic lesions with soft tissue component in the vertebral bodies of T11 and T12, posterior aspects of the left 4 th, 7th
(+) clear vaginal discharge days - Completed and 10th ribs, and lateral aspect of the right 8th rib, worrisome for osseous metastases. Gyne wise
5. Non-specific sclerotic foci in the vertebral bodies of T6 and T7. DEFINITIVE PLAN: For palliative chemotherapy
Gyne wise 6. Heterogeneous liver parenchyma with vaguely-defined hypodensities. Correlation with a dedicated contrast- For referral back to Gyne Onco
(-) vaginal bleeding None for now enhanced For multidisciplinary conference – still for
(-) hypogastric pain CT/MRI is suggested. scheduling c/o main service
Soft flabby abdomen, non- Xray of left femur (05/30/24 OSMAK) There is no significant change in alignment of the comminuted, minimally-displaced fracture of the left proximal femur, Previous plans:
tender, no palpable mass probable pathologic fracture secondary to bone metastasis. Ideally For repeat internal examination c/o Gyne
Minimal callous formation is noted. Onco once IM nailing done, then resume
Gyne onco PE (03/26) The visualized joint spaces are preserved. remaining 4 brachytherapy sessions
IE: cervix 4-5 cm, smooth Soft tissue appears unremarkable. WOF: vaginal bleeding, hypogastric pain
ectocervix with nodularities Decreased bone mineralization of the left femoral head is noted.
on central portion CXR (05/19/24): No significant chest findings Cardio Notes (05/31/24)
RVE: shortened, thickened CXR (05/13/24): No significant chest findings noted OR plans deferred
and fixed right parametria CXR (05/10/24): No significant chest findings cardiowise no active management
Pelvis AP / Left hip AP-L / Left knee AP-L Unchanged comminuted fracture, left proximal femur, probably pathologic respectfully signing out
Pad count: 0 (05/09/24) refer back if warranted
Cervical Punch biopsy (09/25/2023): POORLY DIFFERENTIATED CARCINOMA.
Palliative and hospice care (06/10)
Noted latest labs
Suggest referral to medicine for management of
UTI
Therapeutics:
1.Revise morphine frequency to morphine 10
mg/tab 1 tab every 4 hours round the clock, with
rescue dose of morphine 10 mg/tab 1 tab as
needed for breakthrough pain
Noted schedule for MDT meeting, palliative
service will be present for this meeting
Psychosocial and emotional support rendered
Pre-family conference form questions of patient:

1: May possible pa po ba na maoperahan ako?
2: Ano na po ang status nang cancer ko? Lumaki,
lumiit, o kumalat?
3: Maguunder go pa po baa ko nang chemo bago
maoperahan?
4: Ano po ang plano saakin? Gagaling po ba ko?
5: Ilang percent po ba ang change ko para
gumaling sa sakit ko nac cancer?
6: Sapat po ba ang treatment na ginagawa po sa
akin para gumaling po ako
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)

Endorsement Census - June 10, 2024 V2

Uploaded by

Copyright:

Available Formats

Endorsement Census - June 10, 2024 V2

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Endorsement Census - June 10, 2024 V2

Uploaded by

Copyright:

Available Formats

OSPITAL NG MAKATI

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

ADMISSIONS OB WARD LR / DR GYNE WARD PERIPHERALS REFERRALS

Hepatitis profile (06/11/24)

No evidence of adnexal mass.

No definite evidence of fluid seen in the posterior cul-de-sac.

Endometrium: 0.78, hyperechogenic IM Pulmo (06/10)

Hypovolemic Hypoosmolar No meds for now

Asymptomatic Bacteriuria No meds for now Asymptomatic Bacteriuria

OB 9 G1P1 (1001) Pregnancy Uterine BPR 110-120/80 DASH CBC IUD

Pedia Pulmo (6/8/24)

LEFT Mid-Calf Mid-Thigh

PATIENT INFORMATION DIAGNOSIS SUBJECTIVE/OBJECTIVE THERAPEUTICS LABORATORIES PLAN/NOTES

Gyne 1 Nulligravid BP 90/60 NPO CBC with PC

[HbsAg] 0.48 < 1.0 Urology 06/07/24)

Histopathology findings (06/05/2024)

6/6 235 137 133 125

GYNE 5 G2P2 (2002) BP 120/80 DAT with SAP CBC with PC

Gyne wise ANES (5/18)

Bed 1 IW G6P5(5015) BPR 120-140/80-90 Light meals CBC

Pad counting: 1 minimally

Pre-family conference form questions of patient:

ARI Bed 5 G2P2 (2002)

Infected Sacral Decubitus Ulcer, unstageable

Prolonged intubation, Subglottic stenosis secondary to prolonged intubation

You might also like