Info On Different Cases
Info On Different Cases
Info On Different Cases
Department of Surgery
September 10-11, 2019
DAILY CENSUS
COD: Dr. Valencia
ROD:Dr. Henrico Jose
JIOD: Chan, Dizon, Kaur, Reddy, Rishad, Salvador
REFERRAL 2 ER DEATH 0
TOS 0 THOC 0
MORTALITY 0 HAMA 0
HAMA 0 ABSCONDED 0
THOC 0 TOS 0
ADMISSIONS (3)
Rebullida Ma. car- D0 Invasive ductal ca Stage III(T3N3iVIO) s/p bi- WM BP: 120/70, PR: 73, RR: 20, Temp.: 37.1.
olina lateral MRM RM
54/F s/p 1st cycle chemotherapy. HJ
Diet: DAT
IVF: PLR1L to run for 8hours
Meds: Ondansetron 8mg/IV 30 minutes prior to chemo
Suite 3
Omeprazole 40mg/IV 30 mins prior to chemo
Docetaxel 120mg + D5W 500cc
Doxorubicin 80mg/IV
Cyclophosphamide 800mg/IV
WOF: Dyspnea and hypotension
Refer.
Mansilla Ber- D0 Closed Femoral neck fracture right; Chronic WM BP: 130/90, PR: 99, RR:23, Temp 36.9
nardita Halili kidney failure stage V due to chronic hyper- IB
70/F tension CAP-resolving; Bronchial asthma; EC
chronic hepatitis B carrier Diet: Low salt low fat diet
IVF: None for now
Diagnostics: CBC with BT, PT/PTT, BUN, CREA, Na, K, FBS, UA, 12-L-ECG, CXR
Pelvic X-ray AP, Cross table lateral right hip, right femur APL.
Meds: None for now except for maintenance meds:
Losartan 50mg/tab, 1/2 tab OD
Amlodipine 200mg/tab, 1 tab BID
Rosuvastatin 10mg/tab, 1tab ODHS
PHIC Prednisone 10mg/tab, 1tab OD X 1 dose
FeSo4+ Folic acid, 1 tab OD
Calcium+ Vitamin D3, 1tab BID
Budesonide BID
For partial hip arthroplasty,right.
Refer to IM for CP clearance
Refer to IM-nephro for clearance and hemodialysis
Secure 2 units of PRBC properly typed and cross matched.
May do wheelchair rides
Not allowed to bear weight on the right lower extremity.
Refer.
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Lachica Ma. Grace D0 Acute Suppurative Appendicitis D0 BV BP: 140/90, PR 91, RR 23, T 37.4
42/F s/p Appendectomy (Sept 10,2019)- 6X2cm HJ Diet: NPO
appendix, suupuration middle to tip, good EC IVF: D5LR to run for 8 hours.
base. Labs: CBC with ABO, UA, PT
Meds: Cefoxitin 2gm/IV
FSW 5 Omeprazole 40mg/IV while NPO
Ketorolac 30mg q8 X 3 doses
Tramadol 50mg q8 PRN for pain
Patient was made to lie down on bed for 6 hours flat.
After appendectomy Diet: DAT
WARD (12)
DIET: of 1800kcal
Victoriano, IVF: D5LR to run for 8 hours
BV
Rjen Vil- Sepsis Etiology to be determined Diagnostics:Repeat CBC post BT
NBB1 D9 D27 JS
lanueva S/P Appendectomy (Aug. 15, 2019) Meds: piperacillin + tazobactam 4.5gm/IV q6, metronidazole
HJ
19/M 500mg/IV q8, tramadol 500mg/IV q8, Omeprazole 40mg/IV OD.
Monitor vital signs every 8 hours.
Refer
Peralta, Justine D5 Ruptured Appendicitis with Localized D4 WM BP: 100/70, PR: 68, RR: 19, Temp: 37.1
22/M Peritonitis HJ
s/p Appendectomy (9/7/19) EC IVF: D5LR to run for 8 hours
DIAGNOSTICS: None
MEDICATIONS: ciprofloxacin 400mg/IV q12, omeprazole 40mg/IV
MSW1 OD, metronidazole500mg/IV OD, paracetamol 300mg/IV q4 PRN for
pain or temp 37.8 C, tramadol 50mg/IV q6 PRN for pain.
Encourage early ambulation
Monitor VS q8
Refer
DIET: DAT
IVF: PLR 1L to run for 16 hours
HEMATURIA SECONDARY TO BLEED- For Labs: Repeat CBC with platelet count post blood transfusion
Manga, Renee ING PROSTATE T/C MALIGNANCY DP Meds: Increase ciprofloxacin 400mg/IV q12, metronidazole
MSW5 D33 500mg/IV q6, Start Tranexamic acid 500mg/IV q8, start vitamin K
62/M S/P IJ Catheter Insertion HJ
S/P HD 1amp/IV q8
Refer back to IM for reevaluation with new labs prior open prosta-
tectomy on 9/13/19 at 7am
Follow up for dialysis schedule
Monitor vital signs every 8 hours
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Brusola, D6 Gastric Outlet Obstruction sec to Pan- WM BP: 120/80, CR: 89, RR: 22, Temp: 36.9
Lourdes Yape creatic mass with liver metastasis RF
72/F JS DIET: Soft diet+ Ensure
HJ IVF: D5LR 1L to run for 8 hours
EC Diagnostics: For endoscopy
Meds: Omeprazole 40mg/IV OD
FSW5 HNBB 10mg/IV q8 PRN for pain,
Tramadol 50mg/IV q8 PRN for pain
Start Vitamin K 1amp q8 X 5 doses
Maintain IFC and NGT
Secure 4 bags TRN, 1900kcal
Secure 4 units of PRBC properly typed and crossmatched.
Refer
Gallardo, Mi- D6 DM foot ( R) Wagner V OO BP: 110/70 CR: 85 RR:19 TEMP: 36.5
guela HJ
55/F Diet: DM diet
IVF: PNSS 1L for 16 hours
Meds: Piperacillin-tazobactam 4-5gm/IV q8, Tramadol 50mg/IV q8
407 PRN, Vitamin K 1Amp/IV q8
Start CBG monitoring q4
Refer to IM Regarding FBS for comanagement
Secure 3 units of PRBC, then transfer 2 units of PRBC properly typed
and crossmatched.
Refer
Adona, Mi- D1 Fracture close complete displaced, BV BP: 90/60 , PR:66, RR:19, T:37.0
caella Mae Humerus Right EC
16/F Diet: DAT
IVF: D5LR 1L to run for 8 hours
PSW Diagnostics: Chest X-RAY PA
Medications: Start cefuroxime 750mg TIV q8
For ORIF and Plating of right humerus on Sept 12,2019 @ 7am
Monitor VS Q4
Conejos, Vin- D1 Fracture Tibia Fibula Right D0 OO BP:100/70 , PR: 100 , RR: 20 , T: 36.5
cent 17/M s/p ORIF Intramedullary Nailing Tibia/
Plating Fibula (R) ( Sept 10,2019) Continue Cefuroxime 750mg IV q8
PSW
Keep affected extremity elevated, cold compress right leg q6
Please facilitate X-ray right leg AP
Olita, Raffy D1 Fracture Radius Ulnar D0 OO BP: 120/80, PR: 97, RR: 18, T: 36.7
33/M s/p ORIF radius-ulna
Continue Cefuroxime 750mg IV q8
ISO 1
Labs: X-ray left forearm AP/lateral view
Refer
Singular, Ga- D2 Acute Cholecystitis BV BP: 140/100, PR: 105, RR: 20, Temp.: 37.5
briel T/C Hydrops Gallbladder JS
47/M R/O Hepatic Malignancy Diet: NPO
IVF: D5LR 1L to run for 8 hours
ISO3 For risk assessment prior to open ‘E’ cholecystectomy scheduled on
sept 11,2019.
Continue IV medications
Referred to IM for co-management of hypertension
Refer
POST
WARD/BED # PATIENT HD DIAGNOSIS MS Remarks
OP
GS notes(09/10/2019):
Repeat Baby Gram
Newborn ES
NICU Punan NB D2 Observe bowel movements
t/c Intestinal Obstruction HJ
Continue rectal Stimulation if no bowel movements
Refer
Page 3 of 5
REFERRALS (9)
POST
WARD/BED # PATIENT HD DIAGNOSIS MS Remarks
OP
Empleo, Jay ES
Pedia Surgery notes:
GASTRO3 Jay D11 Necrotizing enterocolitis HJ
Defer Colonogram
1/M
Discharged (3)
POST
WARD/BED # PATIENT HD DIAGNOSIS MS Remarks
OP
Page 4 of 5
Sibbaluca, D4 Acute Suppurative Appendicitis D3 WM Discharged
Philhealth Jerwin S/P Appendectomy (9/8/19) HJ
35/M
Mortality(0)
POST
WARD/BED # PATIENT HD DIAGNOSIS MS Remarks
OP
Page 5 of 5