OSPITAL NG MAYNILA MEDICAL CENTER

Department of Surgery
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

Name : AURO, ERLINDA FULGENCIO Hospital : 85103

Number
Address : BLK. 5 LOT 3 SITIO KABATUHAN DR. COMP.2 GEN T., Age/Sex : 69/F
CITY OF VALENZUELA
Date of Admission : 09/27/2020 Time of : 7:40 PM
Admission
Date of Discharge : 11/02/2020 Time of : 10:00 AM
Discharge
Admitting : INVASIVE DUCTAL CARCINOMA RIGHT ST IVB
Diagnosis
Final Diagnosis : INVASIVE DUCTAL CARCINOMA ST IIIB (T4N1M0)
S/P NEOADJUVANT CHEMOTHERAPY X 8 CYCLES
S/P INCISION BIOPSY
S/P MODIFIED RADICAL MASTECTOMY, RIGHT
LATISSIMUS DORSI, V-Y FLAP (OMMC, OCTOBER 29
2020)
Physicians-in- : Specialty : Surgery
Drs. Benosa/Gaddi/Dela Cruz, Gaspillo
Charge
PGI-in-Charge : PGI Abu Hajar, Agarin, Alo, Azores
Clerk-in-Charge : JI Catalan, Chang, Dizon, Espinosa, Estebal, Fernando

REASON FOR ADMISSION: This is a case of a 69 year old female who came in for wound in right
breast.

HISTORY OF PRESENT ILLNESS

3 years PTA, Patient has a small mass palpated on the 12 o’clock position on the right breast.
2 years PTA, mass progressed in size and consulted at another institution. Mammogram and biopsy were done, and no
malignancy noted.
1 year PTA, there is a progression of mass to draining, hence sought consult . Biopsy was done and revealed invasive
ductal Ca. She started chemotherapy on October 2019 to July 2020 with 8 cycles. She was advised to undergo surgery.

Pertinent Past Medical History: Put an “x” Mark if Asthma

present
Thyroid, kidney, liver disease
PTB
HPN
DM X
Previous operation
Previous hospitalization

FAMILY HISTORY PERSONAL AND SOCIAL HISTORY

Non-smoker
Non-alcoholic beverage drinker
Denies illicit drug use

PERTINENT SIGNS AND SYMPTOMS ON ADMISSION (Put an “x” Mark if present):

Altered mental Diarrhea Hematemesis Palpitations
sensorium
Abdominal cramp/pain Dizziness Hematuria Seizures
Anorexia Dysphagia Hemoptysis Skin rashes
Bleeding gums Dyspnea Irritability Stool, bloody/black
tarry/mucoid
Body weakness Dysuria Jaundice Sweating
Blurring of vision Epistaxis Lower extremity edema Urgency
Chest pain/discomfort Fever Myalgia Vomiting
Constipation Frequency of Orthopnea Weight loss
urination

CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ 11/02/2020
Signature over Printed Name of Attending Health Care Professional Date
 OSPITAL NG MAYNILA MEDICAL CENTER
Department of Surgery
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

Cough Headache Pain, _______ (site) Others:

PHYSICAL EXAMINATION ON ADMISSION (Pertinent Findings per System)

Put an “x” Mark if present

General Survey Awake and alert X Altered sensorium Weight:
Others:
Vital signs BP HR RR: Temp
HEENT Essentially X Abnormal pupillary Cervical Dry mucous
normal reaction Lymphadenopathy membrane
Icteric sclerae Pale conjunctivae Sunken eyeballs Sunken fontanelle
Others:
CHEST/LUNGS Essentially Asymmetrical chest Decreased breath Wheezes
normal expansion sounds
Lump/s over X Rales/Crackles/Ronch Intercostal
breast(s)- right i rib/Clavicular
retraction
Others:
CVS: Essentially X Displaced apex beat Heaves and/or Pericardial bulge
normal thrills
Irregular rhythm Muffled heart sounds Murmur
Others:
Abdomen: Essentially X Abdominal rigidity Abdomen Hyperactive bowel
normal tenderness: sounds
Others:
GU (IE): Essentially Blood stained in exam Cervical dilatation Presence of
normal finger abnormal discharge
Others:
Skin/Extremities Essentially X Clubbing Cold clammy skin Cyanosis/mottled
: normal skin
Edema/swelling Decreased mobility Pale nailbeds Poor skin turgor
Rashes/petechiae
Others:
NEURO-EXAM Essentially X Abnormal gait Abnormal position Abnormal/decreased
normal sense sensation
Abnormal Poor/altered memory Poor muscle Poor coordination
reflex(es) tone/strength
Others:

Referred from another health care Name of Originating HCI:

institution (HCI)?
If yes, specify reason:

COURSE IN THE WARD (Attach photocopy of laboratory/imaging results)

Date DOCTOR’S ORDER

Admitting Notes Patient admitted under the service of Drs. Benosa/Gaddi/Dela Cruz, Gaspillo
Secured consent for this admission. Patient was put on diet as tolerated. Dx: CBC, UA, BUN, CREA,
Na, K, Cl, AST, ALT, CXR, 12L ECG. Tx: Paracetamol 500mg/tab q4 prn. For ‘El’ Modified Radical
Mastectomy Right. Secured consent and materials. VSq4. Refer.
9/29/20 No DOB, no chest pain, no febrile episode, no respiratory symptoms. Patient placed to diet as
(4:35PM) tolerated. IVF: none for now. For CP clearance and anesthesia clearance. For COVID RT PCR
swab. For OR scheduling. Refer
9/30/2020 No DOB, no chest pain, no abdominal pain, afebrile. Patient was still on diet as tolerated. Dx: ECG,
(5:30 PM) CXR, RTPCR. For CP and anesthesia clearance. For OR scheduling. Refer.
10/1/2020 No DOB, no chest pain. Secured anesthesia clearance. Dx: SARS-COV2 RTPCR, BT with Rh, 12L
(7:30 AM) ECG. Tx: 1. Ferrous Sulfate 1 tab OD 2. Folic Acid + Vitamin B Complex tab OD. Secure 1u PRBC
properly typed and crossmatched for possible OR use. Refer.
10/2/2020 No DOB, no chest pain, no abdominal pain. Patient placed to low salt, low fat diet. Tx: 1. Ferrous
(6:30 PM) Sulfate tab OD 2. Folic Acid + B complex tab OD. Still for clearance ad risk stratification. For MRM
CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ 11/02/2020
Signature over Printed Name of Attending Health Care Professional Date
 OSPITAL NG MAYNILA MEDICAL CENTER
Department of Surgery
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

right. Secure 1u PRBC. VSq4h. Refer.

10/3/2020 No chest pain, no dyspnea, no nausea and vomiting, no abdominal pain. Patient placed to low salt,
(10:45 AM) low fat diet. Tx: 1. Ferrous Sulfate 1tab OD 2. Folic Acid + Vit B Complex 1 tab OD. Still for elective
MRM, right. Secure consent and materials. Secure 1u PRBC properly typed and crossmatched. For
deep breathing exercises. VSq4h. Refer.
10/5/2020 No chest pain, no dyspnea, no breast pain, no nausea and vomiting, no febrile episode. Patient still
(10:00 AM) on low salt, low fat diet. Adequate oral fluid intake. Tx: 1. Ferrous sulfate 1tab OD 2. Folic acid + B
complex 1 tab OD 3. Multivitamins 1 tab OD. For elective MRM, Right. Still for CP clearance and risk
stratification. Secure consent and materials.. Secure 4u PRBC properly typed and crossmatched.
Deep breathing exercise. VSq8h. Refer
10/6/2020 No chest pain, no dyspnea, no N/V, no fever, no tachycardia, negative on RT PCR. Patient was still
(3:30 PM) on low salt, low fat diet. Adequate oral fluid intake. Tx: 1. Ferrous sulfate 1 tab OD 2. Folic acid + B
complex 1 tab OD. For elective MRM, right. Still for CP clearance and risk stratification. Secure
consent and materials. Still to secure 4U PRBC properly typed and crossmatched. Deep breathing
exercise. VSq8h. Refer.
10/9/2020 No chest pain, no change in sensorium, no dyspnea, no melena. Placed on DM diet. Dx: BT with Rh,
(8:00 PM) FBS, Lipid profile, HbA1c, 2D-Echo with DS, CBG TID. Tx: 1. Secure 2U PRBC properly typed and
crossmatched for possible OR use 2. FeSO4 1 tab BID 3. Folic acid + Vitamin B complex 1 tab OD
4. Insulin Glargine 10u SQ ODHS 5. Regular insulin 5u SQ PRN if CBG ≥ 180mg/dL 6. Atorvastatin
40mg 1 tab ODHS 7. Carvedilol 6.25mg ½ tab BID. For moderate to high back rest. VSq4h with
O2stat. CBG TID and record. Refer.
10/12/2020 No dyspnea, no chest pain, no abdominal pain, no N/V. Still on DM diet. IVF: heplock. DX: FBS,
(12:00 PM) Lipid profile, HbA1C, 2D-Echo. Tx: 1. FeSO4 1 tab BID 2. Folic acid + Vit B complex 1 tab OD 3.
Insulin glargine 10u SQ ODHS 4. Regular Insulin 5U SQ PRN if CBG ≥ 180mg/dL 5. Atorvastatin
40mg/tab ODHS 6. Carvedilol 6.25mg ½ tab BID. Moderate to high back rest. VSq4h, CBG TID.
Refer.
10/14/2020 Patient out on pass for 2D Echo.
(4:08 PM)
10/15/2020 Patient maintained on DM diet. IVF: still on heplock. Tx: continue medications. Still for elective MRM,
(8:47 PM) Right. Still for CP evaluation and Risk stratification. To secure 1unit PRBCS properly typed and
crossmatched for OR use. VSq4h, CBG TID and record. Refer.
10/16/20 Patient is awake, coherent, not in cardiorespiratory distress, no subjective complaints. Patient still on
(11:15PM) DM diet. IVF: heplock. Tx: continue medications. Still for elective MRM, right. Secure 1U PRBC for
possible OR use. VSq8h. Refer.
10/18/20 No subjective complaints. Still on DM diet. IVF: heplock. Tx: continue medications. Still for elective
(9:15 AM) MRM, right. Secure 1U PRBC for possible OR use. VSq8h. Refer.
10/19/20 No subjective complaints. Still on DM diet. IVF: heplock. Tx: continue medications. Still for elective
(6:25 PM) MRM, right. Secure 1U PRBC for possible OR use. VSq8h. Refer.
10/20/20 No subjective complaints. Still on DM diet. IVF: heplock. Tx: continue medications. Still for elective
(7:30 PM) MRM, right. Secure 1U PRBC for possible OR use. VSq8h. Refer.
10/21/2020 Awake, coherent, not in cardiorespiratory distress. No subjective complaints. Still on DM diet. IVF:
(8:00 PM) heplock. Tx: continue medications. Still for elective MRM, right. Secure 1U PRBC for possible OR
use. VSq8h. Refer.
10/23/2020 No subjective complaints. Still on DM diet. IVF: heplock. Tx: continue medications. Still for elective
(7:00 AM) MRM, right. Secure 1U PRBC for possible OR use. VSq8h. Refer.
10/24/2020 Patient was on DM diet. IVF: may not reinsert heplock. Dx: CBC with PC. Tx: 1. FeSO4 1tab OD 2.
(10:00 AM) Folic Acid + Vit B Complex OD 3. Insulin glargine 10U SQ ODHS 4. Atorvastatin 40mg 1 tab ODHS
5. Carvedilol 6.25mg/tab 1/2tab BID. For elective MRM, right. VSq8h. Refer
10/25/2020 No chest pain, no abdominal pain. Patient was on DM diet. Tx: Continue meds. For elective MRM,
(7:00 AM) right. VSq8h. Refer
10/27/2020 No chest pain, no abdominal pain. Patient was on DM diet. Tx: Continue meds. For elective MRM,
(7:00 PM) right. VSq8h. Refer
10/28/2020 No chest pain, no dyspnea, no N/V, no febrile episodes. Patient was on DM diet. Tx: Continue meds.
(11:30AM) For elective MRM, right. VSq8h. Refer
10/28/2020 Dx: crossmatching, repeat CBC post BT after 6hrs. Transfuse 1U PRBC properly typed and
(7:00PM) crossmatched. Secure 1 more unit PRBC for OR use. Refer.
10/29/2020 Secured anesthesia clearance. Tx: none. Secure 1U PRBC properly typed and crossmatched.
(12:15PM) Secure 1 more unit PRBC for OR use. Refer.
10/29/2020 S/P MRM, Right, Latissimus Dorsi Flap. NPO temporarily. IVF: PLR 1L x 100cc/hr. SD: Tramadol
(11:00 PM) drip 6oomg tramadol in 500cc PNSS x 48hrs (at wards) Dx: post op CBC with PC, Na, K, Cl, BUN,
CREA, 12L ECG. Tx: 1. Omeprazole 40mg TIV Od 2. Cefazolin 1g TIV Q8 3. Paracetamol 600mg
TIV Q6 RTC 4. Pain meds c/o anesthesia 5. Regular insulin 5U SQ PRN if CBG ≥ 180mg/dL 6.

CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ 11/02/2020
Signature over Printed Name of Attending Health Care Professional Date
 OSPITAL NG MAYNILA MEDICAL CENTER
Department of Surgery
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

D5050 vial TIV PRN if CBG ≤ 80mg/dL 7. Captopril 25mg tab SL PRN if BP ≥ 180/100. Refer to IM
for post-op status/orders. Maintained on elastic bandage for DVT prophylaxis. Maintain post-op
dressing for 48hrs unless fully soaked. Monitor VSq1, I/Oq1h, CBGq1h. Refer.
10/30/2020 No DOB, no chest pain, no hematoma, afebrile, no chest pain. Patient placed on diet as tolerated.
(3:30AM) IVF: PLR 1L x 100cc/hr. Continued side drip. DX: CBC, BUN, CREA, Na, K, Cl. Tx: 1. Omeprazole
40mg TIV OD 2. Cefazolin 1g TIV Q8 3. Paracetamol 600mg TIV PRN 4. Regular insulin 5U SQ
PRN 5. D5050 vial TIV PRN 6. Captopril 25mg tab SL PRN. Refer.
10/31/2020 Awake, coherent, NICRD, no subjective complaints, tolerated post op site pain, minimal violaceous
(9:15 AM) discoloration on wound edge viable flap, serosanguineous JP drain output. Patient was on diet as
tolerated. IVF: PLR 1L x100cc/hr. Discontinue tramadol drip. Tx: 1. Discontinue omeprazole,
continue present meds. Maintain on JP drain. Refer.
10/31/2020 IVF: to consume. Shifted intravenous to oral medications. Tx: 1. Cefuroxime 500mg tab Q8 2.
(11:00 AM) Tramadol + Paracetamol tab Q8 3. Celecoxib 200mg tab OD 4. MV tabs OD 5. Ascorbic acid tab OD
6. Vit B complex + Folic acid tab OD 7. Ferrous sulfate 1tab OD. Proper wound care daily. Maintain
on JP drain. VSq4h. Refer
11/1/2020 No DOB, no chest pain, no febrile episodes. Tx: continue present meds. Mupirocin ointment TID.
(8:30PM) Maintained JP drain. Daily body hygiene. VSq4h. Refer.
11/2/2020 MGH. THM: 1. Cefuroxime 500mg tab Q8 x 7D 2. Tramadol + Paracetamol 37.5/325mg tab Q8 PRN
(10:00AM) for pain 3. Celecoxib 200mg 1cap Q12 4. MV tab OD 5. Ascorbic acid tab OD 6. Vit B complex +
Folic acid tab OD 7. Ferrous sulfate 1tab OD. To start mupirocin ointment TID. Keep JP drain on
negative. Daily body hygiene. Well-advised. Follow up at Surgery Telemedicine.
SURGICAL S/P Modified Radical Mastectomy, Right for Invasive Carcinoma right breast, St. IV B
PROCEDURE/RVS
CODE (Attach
photocopy of OR
technique):

Hematology 9/28/2020 Chemistry 9/28/2020

(11:52 AM)
WBC 4.90 Sodium 136
Neutrophils 57.80 Potassium 4.1
Lymphocytes 29.60 Chloride 99
Monocytes 9.40 BUN 5.1
Eosinophils 2.20 CREA 58
Basophils 1.00 eGFR 90.42
RBC Count 4.50 AST 24
Hemoglobin 10.0 ALT 21
Hematocrit 31.5
MCV 69.9
MCH 22.2
MCHC 31.7
RDW-CV 15.1
Platelet Count 248
BT AB (-)

CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ 11/02/2020
Signature over Printed Name of Attending Health Care Professional Date
 OSPITAL NG MAYNILA MEDICAL CENTER
Department of Surgery
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

Chemistry 10/13 Hematology 10/13 (10:11 Urinalysis 10/13

(10:51 AM) PM) (12:39PM)
Glucose 6.8 WBC 7.0 Color Yellow
Total Cholesterol 5.5 Neutrophils 79..40 Transparency Clear
Lymphocytes 11.50 Blood Negative
Triglycerides 2.6 Monocytes 8.90 Bilirubin Negative
HDL 1.07 Eosinophils 0.00 Urobilinogen Negative
LDL 3.27 Basophils 0.20 Ketone Negative
RBC Count 3.61 Protein Negative
VLDL 1.16
Hemoglobin 8.4 Nitrite Negative
HbA1c 7.9 Hematocrit 25.8 Glucose Negative
MCV 71.5 pH 6.0
MCH 23.1 Specific Gravity 1.025
MCHC 32.3 Leukocytes Negative
Hematology 10/25 RDW-CV
Hematology 16.3 10/28 Epithelial cells
Hematology Few 10/29
(12:28 PM) Platelet Count 147 Mucus thread Occasional
(10:51 AM)Amorphous urates Occasional
WBC 5.3 PT- Reference 12.60 WBC WBC 0-2 5.3
RBC 0-1
Neutrophils 54.60 PT-Time 12.60 Neutrophils 62.9
Bacteria
Lymphocytes 31.40 PT% 100 Lymphocytes 22.1
Monocytes 9.60 PT-INR 1 Monocytes 10.2
Eosinophils 3.40 APTT-Reference 30.38 Eosinophils 4
Basophils 1.00 APTT-Time 22.9 Basophils 0.8
RBC Count 4.35 RBC Count 5.1
Hemoglobin 9.6 Hemoglobin 11.7
Hematocrit 29.8 Hematocrit 36.2
MCV 68.4 MCV 70.9
MCH 22.1 MCH 23
MCHC 32.3 MCHC 32.4
RDW-CV 14.0 RDW-CV 16.5
Platelet Count 209 Platelet Count 205

Hematology 10/29
WBC 5.3
Neutrophils 62.9
Lymphocytes 22.1
Monocytes 10.2
Eosinophils 4
Basophils 0.8
RBC Count 5.1
Hemoglobin 11.7 CERTIFICATION OF HEALTH CARE PROFESSIONAL
Hematocrit 36.2
MCV I certify that70.9
the above information given in this form, including all attachments, are true and correct.
MCH 23
MCHC 32.4
________________________________________ 11/02/2020
RDW-CV
Signature over Printed Name 16.5
of Attending Health Care Professional Date
Platelet Count 205
 OSPITAL NG MAYNILA MEDICAL CENTER
Department of Surgery
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

Take home medications:

Generic Name Instructions

Uminom ng isang (1) tablet kada walong (8) oras sa loob ng pitong (7) araw
Cefuroxime 500mg/tab
Tramadol + Paracetamol Uminom ng isang (1) tablet kada walong (8) oras para sa kirot
37.5/325mg/tab
Uminom ng isang (1) capsule kada labing-dalawang (12) oras
Celecoxib 200mg/cap
Uminom ng isang (1) tablet kada araw
Multivitamins tab
Uminom ng isang (1) tablet kada araw
Ascorbic Acid 500mg/tab
Vitamin B Complex + Folic Acid Uminom ng isang (1) tablet kada araw
tab
Uminom ng isang (1) tablet kada araw
Ferrous Sulfate tab
Ipahid and ointment tatlong (3) beses kada araw sa sugat
Mupirocin Ointment

Mag-follow up sa Surgery Telemedicine

CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ 11/02/2020
Signature over Printed Name of Attending Health Care Professional Date