PASAY CITY GENERAL HOSPITAL

Department of Surgery
September 10-11, 2019
DAILY CENSUS
COD: Dr. Valencia
ROD:Dr. Henrico Jose
JIOD: Chan, Dizon, Kaur, Reddy, Rishad, Salvador

WARD CENSUS ER CENSUS

TOTAL NUMBER OF IN PATIENTS 15 TOTAL NUMBER OF PATIENTS 91

ADMISSION 3 NON-MEDICO LEGAL 39

DISCHARGE 3 MEDICO LEGAL 52

REFERRAL 2 ER DEATH 0

TOS 0 THOC 0

MORTALITY 0 HAMA 0

HAMA 0 ABSCONDED 0

THOC 0 TOS 0

ADMISSIONS (3)

WARD/BED # PATIENT HD DIAGNOSIS POST MS REMARKS

OP

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)

PATIENT HD DIAGNOSIS POST MS REMARKS

WARD/BED #
OP

BP: 100/60, CR: 82, RR: 20, Temp: 36.4

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

BP: 120/80, CR: 80, RR: 20, Temp: 37

FRACTURE , CLOSED, COMMINUTED,
Dalanang-
DISPLACED, MIDDLE 3RD FEMUR, LEFT IB
MSW3 bayan, Rene D11 D8
S/p Open reduction intramedullary JS For discharge after ambulation training
38/M
nailing of left femur (9/3/19) Remove IFC

BP: 110/70, CR: 67, RR: 22 , Temp: 36.9 JP drain = cc

SQUAMOUS CELL CARCINOMA, BUC- DIET: OF 2300 kcal

D15 IVF: PLR1L to run for 16 hours
CAL MUCOSA Stage 3 (T3N1M0) WM
Logarto, Sa- Labs: None
s/p Wide Excision of Modified Radical RM
MSW4 turio D28 Meds: cefazolin 1gm/IV q8, tramadol 50mg/IV q6 PRN
Neck Dissection, Left Cheek Defect JS
51/M Wound care
(8/27/19) HJ
D4 Maintain JP drain negative pressure
s/p Pectoralis Major Flap Flap, Left,
Repair of left cheek defect (9/7/19) Monitor VS Q8

BP:130/90 RR:22 CR: 99 T: 36.5

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

BP: 130/80, CR: 75, RR: 20, Temp: 36.7

Acampado, D9 Partial Gut Obstruction probably sec- WM
Marcelina ondary to gyne pathology JS Diet: Liquid
63/F EC IVF: D5LR 1L to run for 8 hours.
FSW3
Diagnostics: Follow up official CT scan results
Home medications:Cefoxitin 1g/IV q8, HNBB 10mg/IV q8 PRN for
pain
Refer

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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

NEW REFERRALS (2)

POST
WARD/BED # PATIENT HD DIAGNOSIS MS Remarks
OP

Pedia Surgeon notes(09/10/2019):

Newborn MGH anytime
Velasquez ES
NICU D2 Hemangioma Chest, Nipple area Left For UTZ as OPD
BB Boy HJ
side. May follow up with result in a month.
Refer.

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

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 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

TCVS Notes (8/29/19):

History and PE reviewed
Ilano, Pacita EE If patient has right atrial or ventricular collapse on diastole then TCVS ser-
ICCU D15 PERICARDIAL EFFUSION
74/F JS vice will drain the pericardial effusion
Refer back once with updates

Orthopedic surgery notes (9/3/19):

Aspiration of fluid in bullae done
Sible, Erlinda
OO Medical management for now
FMW1 75/F D8 Cellulitis Right Leg, T2 DM
EC
Referral (9/8/19):
Daily wound care and for possible debridement

General Surgery Notes (9/3/19):

HX and PE reviewed
(+) Necrotic wound with minimal discharge
Javier, Marci- Decubitus ulcer, Grade IV
HM
405 anna Cruz D9 DECUBITUS ULCER, GRADE IV Apprised relatives of surgical plan of debridement
JS
86/F Awaiting decision of relatives
GS notes (09/10/2019):
For debridement once with full consent of relatives

TCVS Notes (9/6/19):

History and P.E reviewed
Cabrera, Feli- PLEURAL EFFUSION, PROB. PARAPNEU-
MS informed and updated
cidad MONIC EE
ISOL 3 D17 Maintain CTT tube with drain bottle catheter and CTT care
79/F EC
Suggest to do chest CT- scan with contrast
s/p CTT insertion, right
Refer back once with results
Refer accordingly

TCVS Notes (9/8/19):

For “E” CTT, Left
Please prepare materials; inform service once available
TCVS Notes (9/10/19):
Cuello, Flor- Pleural effusion (L) (R) Probably secondary to Repeat CXR prior to transfer to ward
EE
FMW2 delita D10 CKD D0 Start tramadol drip (Tramadol 50mg+ D5W 500cc) to run for
JS
53/F s/p CTT insertion ( 09/10/2019) 24 hours a day.
Drain 100cc of effusion every day and cleanup.
If output is less than 50cc, keep open
Change CTT bottle daily.
Refer

TCVS Notes (9/8/19):

Chronic Kidney disease stage V 2 to diabetic For IJ Catheter insertion- done
Umadhay, EE
MMW11 D6 Nephropathy and Hypertensive Nephroscle- Please secure consent and materials
Pedro EC
rosis Notify OR
Refer accordingly

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

Unday, D6 Ruptured Appendicitis D6 ES Discharged

PSW3
Jhanna 6/F s/p Appendectomy (09/06/19) JS

Daguinod, D9 Ruptured Appendicitis D9 ES Discharged

PSW1 John Ryou s/p Appendectomy (09/02/19) JS
8/M HJ

Mortality(0)

POST
WARD/BED # PATIENT HD DIAGNOSIS MS Remarks
OP

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