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The document provides a discharge summary for a patient who was admitted for a broken ribcage and massive blood loss from an accident. It details the patient's treatment over two weeks in the hospital, including surgery, medications, test results and instructions for follow up care.

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50 views

Untitled Document

The document provides a discharge summary for a patient who was admitted for a broken ribcage and massive blood loss from an accident. It details the patient's treatment over two weeks in the hospital, including surgery, medications, test results and instructions for follow up care.

Uploaded by

mathewmlazarte
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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BICOL MEDICAL CENTER

Concepcion Pequena, Naga City 4400


Tel. no.: (054) 472-61-25 to 31 | Email: [email protected]

1197343
IMPORTANT REMINDERS ALAGANG PINOY TAGUBILIN
THIS FORM SHOULD BE FILLED UP-LEGIBLY
DISCHARGE SUMMARY

Health Record Number 1193743 Age/Edad: 21 yr(s). old

Name of Patient/Pangalan Sex/Kasarian: Female Chief Complaint / Reason for Admission:


ADAYO KATE SHARMAINE JACO BROKEN RIBCAGE / MASSIVE BLOOD LOSS
Last Name First Name Middle Name

Date Admitted: 05/31/2023 Time Admitted: 3:00 pm


Month Day Year hh: mm : am/pm

Date Discharged: Time Discharged:


Month Day Year hh: mm : am/pm

Brief History of Present Illness / History:


14 DAYS, THE PATIENT EXPERIENCED NOSE BLEEDING,VOMITING, HIGH FEVER AND HEADACHE.
2 DAYS PRIOR TO ADMISSION, THE PATIENT STILL EXPERIENCE VOMITING AND STILL HAS HIGH FEVER.
FEW HOURS BEFORE ADMISSION, THE PATIENT HAD HEAVY EPISTAXIS.

Physical Examination( Pertinent Findings per System)


General survey : Unconscious

Vital Signs : BP: 110/90 CR: 60 RR: 21 Temperature: 36.4

HEENT : Essentially normal GU: High

Chest/Lungs : Low Neuro Exam: For CT Scan

CSV : High

Course in the Wards (attached additional sheets if necessary)


05-31-2023 THE PATIENT SAID TO BE EXPERIENCING MASSIVE BLOOD LOSS DUE TO AN ACCIDENT AND IS SUPERVISED TO BE ADMITTED FOR
FURTHER OBSERVANCE. CT SCAN, XRAY, CHEST XRAY, BLOOD TYPING, URINALYSIS, CBC, HEMOGLOBIN, WBC WAS THE TEST
REQUEST THAT CEPHALOSPORIN 1.5G IV WAS ADMINISTERED
06-01-2023 PRE OP / REQUEST FOR SURGERY DUE TO BROKEN RIBCAGE POST OP/ THE PATEINT IS IN BED REST CONSUMING 24GHTS/20MN
BETA LACTAM. ONCE TRANSFERRED IN WARD, THE PATIENT IS SAID TO TAKE ORAL MEDICATION: TAKE CLINDAMYCIN 500MG/CAP
FOR 7 DAYS FOR INFECTION, ITRACONIDAZOLE 200MG/DAY. FEROUS SULFATE 500MG AS PER ADVISED OF THE DOCTOR. NAPROXEN
500MG FOR PAIN.
06-02-2023 THE PATIENT IS SCHEDULED ON THE OPERATING ROOM, POST OP / THE PATIENT WILL BE TRANSFERRED IN WARD TO TAKE REST.
DAT DIET UNDER 1624 ; SOFT DIET UNTIL RECOVERY
06-03-2023 THE PATIENT IS NOW ON THE WARD AND WILL TAKE ORAL MEDICATIONS; CLINDAMYCIN 500MG/CAP FOR 7 DAYS FOR INFECTION
ITRACONIDAZOLE 200MG/DAY. FEROUD SULFATE 500MG AS PER ADVISED OF THE DOCTOR. NAPROXEN 500MG FOR PAIN.
ITRACONIDAZOLE 200MG/DAY
06-09-2023 THE PATIENT MAY NOW GO HOME AND CONTINUE TO TAKE ORAL MEDICATIONS.

Pertinent Laboratory and Major Diagnostic Results


WHITE BLOOD CELL 10.02; RBC 1.056; HEMOGLOBIN 0.215; PLATELET COUNT 112
HBSAG: NON- REACTIVE
RPR: NON- REACTIVE

Disposition on Discharge
Improved Transferred HAMA Absconded Expired

BMC-F-MED-001 Rev. No. 3 Effectivity Date: February 10, 2016


ADAYO, KATE SHARMAINE JACO

Home Medications/ Gamot


TAKE CLINDAMYCIN 500MG/CAP FOR 7 DAYS FOR INFECTION
TAKE ITRACONIDAZOLE 200MG/DAY.
TAKE FEROUS SULFATE 500MG AS PER ADVISED OF THE DOCTOR.
NAPROXEN 500MG FOR PAIN.

Health Teachings/ Pangunahing Paalalang Pangkalusugan

WELL ADVISED

Other Instructions/ Karagdagng Paalala

FOLLOW UP ON JUNE 16, 2023 AT OPD.

Final Diagnosis / Sakit

(18245) BROKEN RIBCAGE DUE TO ACCIDENT. TRASSFERED BLOOD DUE TO MASSIVE BLOOD LOSS.

Operation/Procedure Done

OP UNDER SUPERVISION OF DR. ANDREW MEDFORD. TREATMENT OF BROKEN FALSE RIBCAGE SEC 4 ORG 2. COMPLETED SURGICALLY (06/02/2023).

Other Procedures
CP / Endo Closed tube thoracostomy
Thoracentesis / Paracentesis Tracheostomy
Endotracheal Incubation Chemotherapy Procedure
Cut down, CPV Others: _____________________
Pleurodesis

Follow-up Check-up

Date of follow-up/Petsa ng Follow up Time/Oras Need to bring / Mga kailangang dalhin

06/09/2023 8:00 am DISCHARGE SUMMARY

Prepared by: Instruction given by:

ANDREW MEDFORD, MD
Phydician-in-Charge Nurse-on-Duty

**Dalhin ang dokumentiong ito sa petsa ng Follow-up


**Para sa karagdagang katanungan, maari kayong tumawag sa Alagang Pinoy helpline: (054) 471-6125

BMC-F-MED-001 Rev. No. 3 Effectivity Date: February 10, 2016

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