Davao Medical School Foundation Hospital

DEPARTMENT OF INTERNAL MEDICINE

ENDORSEMENT
February 27-28, 2024
COD Dr.

ICU ROD Dr. LUMBA

WARD SUP Dr. REYES

ER ROD Dr. VIVA

Ward ROD Dr. MONDRAGON

PGI Dr. NITHIN

 24-hour Census
Admissions 0

Referrals 2
REFERRALS :

Room Name Age/ CC Admitting Impression Ward Impression Attending

No. Sex Physician
ADMISSIONS :

Room Name Age/ CC Admitting Impression Ward Impression Attending

No. Sex Physician
Admission #1

NAME : Mr. M R
AGE/ SEX. : 64YRS / M
ADDRESS. :DAVAO CITY
RELIGION : RC
MARITAL STATUS : MARRIED
OCCUPATION : RETIRED ELECTRICIAN
WARD : ER
DATE & TIME PERFORMED : 27-FEB-2024, 4.00 PM
 Chief Complaint

Abdominal pain
History Of Present Illness
 Past Medical History
(+) Surgical - Appendectomy (2019)

(+) Laparoscopy

(+) Seizure Disorder, major depression disorder,Generalized anxiety disorder (2012)

Maintained on Rivotril, vimpat, Lemotrigine.

(+) cholesterol (6mmol) ( borderline high)

Family Medical History
● (+) Hypertension ( mother )
● (-) Diabetes
● (-) Asthma
● (+) Cancer ( thyroid cancer -mother)
Personal Social History

● Patient is non-smoker
● Non-alcoholic
● No food and drug allergy
● Patients regular diet consists of fish, brown rice, fruits.
● Gambling
● He was bullied in childhood because he was very thin , so that he didn't have food for long Days.
Review of Systems
General : (+) Weight loss, (-) Fever

Skin: (-) lesions, (-) itching, (-) Lumps

HEENT: (-) Blurring of vision, (-) ear pain, (-) throat pain, (-) nasal congestion

Respiratory: (-) cough, (-) difficulty in breathing

Cardiovascular: (-) chest pain, (-) palpitations

Gastrointestinal: (-) constipation, (-) diarrhea, (-) bloatedness

REVIEW OF SYSTEMS

Renal & Urinary: (-) polyuria , (-) dysuria

Musculoskeletal: (-) joint pain, (-) muscle pain

Hematological: (-) bleeding, (-) easy bruising

Endocrine & Metabolic: (-) heat intolerance, (-) cold intolerance

Nervous System: (+) anxiety, (-) no personality change (-) memory problem
Physical Examination

GENERAL
Awake, Allert , Not in respiratory distress
SURVEY

BP: 100/60 mmhg, HR: 65 bpm, RR: 20bpm, T: 36.5, O2 sat: 96%
VITAL SIGNS
Wt: 48kg, Ht: 5’5 , BMI:17.6

(-) jaundice , CRT<2 ,warm to touch , Anicteric sclerae, slightly pale

SHEENT
palpebral conjunctiva , pupil reacts to light

NECK (-) CLAD

Physical Examination

CHEST Equal chest expansion, clear breath sounds

HEART Adynamic precordium, Distinct S1 & S2 heart sounds, (-)murmurs

ABDOMEN Flat abdomen , soft, non tenderness

EXTREMITIES (-) edema ,(-) joint pain

Neurologic Examination

Cranial Nerves:

I: able to smell coffee and soap

Level of Consciousness: Awake, coherent(GCS15)
II, III: pupils are equally round and reactive to light
Orientation: Oriented to person, place, and time
III, IV, V: able to follow finger superiorly, inferiorly, laterally,
and obliquely
Memory: Intact
V: able to firmly clench and move jaws side to side
Motor strength
VII: no facial asymmetry, able to raise eyebrows, smile, frown
5/5 on all upper and lower LEFT extremities
5/5 on all upper and lower RIGHT extremities VIII: able to hear without difficulty

Sensory IX, X: able to swallow

100% on all upper and lower extremities.
XI: able to shrug against resistance

XII: able to protrude tongue without deviation

Laboratory Results
Complete Blood Count Chemistry ABG

Na- 139.60 pH - 7.37

Hgb 81 (L)
K- 4.52 PC02 - 29.2 L
Hct 0.25 (L) PO2 - 166
RBC 2.78 (L) iCa- 1.22 HCO2 - 16.8
WBC 7.0 Mg- 0.72 (L) tCO2 - 17
MCV 90 BEecf - 8.3
MCH 29.10 sO2 -99% H
MCHC 32.4
Segmenters .46
Lymphocytes 0.40
Monocytes 0.07
Eosinophil 0.07 (H)
Basophil 0.00
Platelet count 188
EKG

HR : 100
Rhythm- regular
Axis- normal axis
PR- 0.2s
QRS-0.08s
QT- 0.4s
Impression- normal sinus rhythm
CXR
Exposure Adequate exposure

Expansion Good expansion

View AP

Airway Trachea is in midline

Bone No bone or tissue abnormalities

CT ratio Ct ratio <0.5

Diaphragm Costophrenic and cardiophrenic angles

are sharp

Infiltrates None

impression Unremarkable pulmonary Findings

Admitting Impression

Drug overdose ( Clonazepam, Lacosamide, Lemotrigine)

Seizures And anxiety
Bronchitis
Management

● Pantoprazole 40mg IV
● Kcl 1tab TID ×2d
● Caco3 1tab BID
● Diazepam 5mg IV ( ACTIVE SEIZURE)
Plan

● Monitoring patient in ICU.

● Once he gets better, shift to private room.
Admission #2
CC
73/F
 Chief Complaint

Dyspnea
 History Of Present Illness
3 days PTA Patient had a onset of dry cough associated with shortness of breath , chills . No other symptoms like fever,running
nose. Patient consumed her maionce,medication which offered only temporary relief. No consultation done.

Interim , symptoms persisted

On the day of admission, persistent of above symptoms, leds patient to seek consultation and subsequent admission. Hence this
admission.
PAST MEDICAL HISTORY
(+) admitted- asthma attack (shortness of breath) Dec 2023
(+) surgery - cataract both eye (2020)
(+) Hypertension -1994
Maintained by losartan 50mg OD , Amlodipine 10mg OD
UBP- 120/80 ,HBP 200/180
(+) DM -(2020) sitagliptin 100mg OD
(+) bronchial asthma -2021
Maintained by montelukast 10mg OD, doxycyline 400mg BID,
Tiotropium inhaler OD , salbutamol Nebulizer upon SOB
Seratide 250/50mcg 2×a day
(+) allergic to dust
FAMILY HISTORY
● (+) Hypertension - son,daughter, husband
● (+)Diabetes- husband
● (+) Asthma - husband
● (+) Cancer ( breast Cancer - sister)
PERSONAL & SOCIAL HISTORY

Patient retired
No smoking, No alcoholic
Regular diet consist Of rice and fish
REVIEW OF SYSTEMS

General : (-) Weight loss, (-) Fever

Skin: (-) lesions, (-) itching, (-) Lumps

HEENT: (-) Blurring of vision, (-) ear pain, (-) throat pain, (-) nasal congestion, (+)left neck
pain

Respiratory: (-) chest tightness

Cardiovascular: (-) chest pain, (-) palpitations

Gastrointestinal: (-) constipation, (-) diarrhea, (-) bloatedness

REVIEW OF SYSTEMS

Renal & Urinary: (-) dysuria, (-) polyuria, (-) hesitancy, (-) urgency

Musculoskeletal: (+)arm pain , (-) myalgia, (-) arthralgia

Hematological: (-) spontaneous bleeding, (-) easy bruising

Endocrine & Metabolic: (-) heat/cold intolerance, (-) excessive sweating

Nervous System: (-) tremors, (-) syncope

Physical Examination
GENERAL
Awake, Alert, in respiratory distress
SURVEY

BP: 140/79 mmHg, HR: 115, RR: 21, T: 37.1 O2sat: 92%, Wt: 69 kg,
VITAL SIGNS Ht: 158cm , BMI:

Warm to touch, Anicteric sclera, pink palpebral conjunctiva, pupils react

SHEENT to light, no ear discharge

(-) lesions, (-) masses, (-) neck vein distention; (-) cervical
NECK lymphadenopathy
Neurologic Examination Cranial Nerves:

I: able to smell coffee and soap

Level of Consciousness: Awake, coherent(GCS15) II, III: pupils are equally round and reactive to
light
Orientation: Oriented to person, place, and time
III, IV, V: able to follow finger superiorly,
Memory: Intact inferiorly, laterally, and obliquely

Motor strength V: able to firmly clench and move jaws side to

5/5 on all upper and lower LEFT extremities side
5/5 on all upper and lower RIGHT extremities
VII: no facial asymmetry, able to raise
eyebrows, smile, frown
Sensory
100% on all upper and lower extremities. VIII: able to hear without difficulty

IX, X: able to swallow

XI: able to shrug against resistance

XII: able to protrude tongue without deviation

Physical Examination

CHEST/LUNGS Equal Chest Expansion,(+) wheezing on both lung field

Adynamic precordium, Distinct S1 and S2, No murmurs, No heaves and

HEART
thrills

ABDOMEN Flabby, soft, non-distended, non tenderness

EXTREMITIES full range of motion, no edema

Latest Laboratory Results
Complete Blood ABG Electrolytes
Count
pH 7.47
pCo2 28.2 Na 138.20
Hgb 123 pO2 69 K 4.23
Hct 0.38 HCo2 20 ICa 1.220
RBC 4.03L tCo21.0 Mg 0.78
WBC 16.5 H BEecf -3.4
MCV 94 sO2 95%
MCHC 32.5 L Bicab deficit-
Segmenters 0.84H
L 0.08 L Impression:
M 0.02
Plt 139 L
ECG

Heart Rate- 107bpm

Rhythm- Sinus Regular
PR-0.16sec
QRS -0.08s narrow
QT-0.36sec
Axis: normal axis
Impression: Normal sinus
rhythm
CHEST X-RAY Exposure Adequate exposure

Expansion Good expansion

View AP

Airway Trachea is midline

Bone No bone or tissue abnormalities

CT ratio Ct ratio <0.5

Diaphragm Costophrenic and cardiophrenic angles

are sharp

Infiltrates No infiltrates

Impression Unremarkable chest x ray

 Working impression

BRONCHIAL ASTHMA ACUTE EXACERBATIONS

CAP moderate risk
HYPN
DM TYPE II
Management
Hydrocortisone 100mg NTT Q6
Montelukast 10mg/ tab OD
Doxofylline BID
Seratide inhaler 50/250mcg 2puffs B80mg 1 tab OD
Losartan 100mg tab OD tab OD
Amlodipine 50mg tab OD
Metformin + sitagliptin 100/100 mg tab OD
Azithromycin 500mg tab OD X5 a days
Ceftriaxone 2gm IVTT OD
Salbutamol + Ipatropium
PLANS:
Admission#3

T.D
44/M
Chief Complaint

Immobility in left arm

 History Of Present Illness
2 hrs prior to admission,patient was not able to move his left arm,No medication taken,pain scale was 9/10.
1 hrs prior to admission,patient was not able to move his left arm,there is tingling sensation in his left leg.
The patient was not able to speak clear,he took cortisone.
This prompts the consultation.
PAST MEDICAL HISTORY

He was diagnosed with hypertension on 2007,taking amlodipine,carvedilol,clonidine.

He was diagnosed with unknown CVD 5 yrs ago-entrego atorvastatin.
Kidney Transplantation was done on 2011.
PERSONAL & SOCIAL HISTORY

Low potassium,sodium diet

Non smoker,non alcoholic
Offen do arm exercise
FAMILY HISTORY

No family history of hypertension

No family history of diabetes
No family history of asthma
No family history of cancer
Father had mild stroke
REVIEW OF SYSTEMS

General: (-) weight loss, (-) easy fatigability

Skin: (-) pruritus, (-) rashes, (-) lumps

HEENT: (-) blurring of vision, (-) hearing problem, (-) nasal congestion, (-) sore throat

Respiratory: (-) dyspnea

Cardiovascular: (-) chest pain, (-) palpitations

Gastrointestinal: (-) diarrhea, (-) constipation, (-) hematochezia, (-) melena

REVIEW OF SYSTEMS

Renal & Urinary: (-) dysuria, (-) polyuria, (-) hesitancy, (-) urgency

Musculoskeletal: (-) myalgia, (-) arthralgia

Hematological: (-) spontaneous bleeding, (-) easy bruising

Endocrine & Metabolic: (-) heat/cold intolerance, (-) excessive sweating

Nervous System: (-) tremors, (-) syncope

Physical Examination
GENERAL
Awake, Alert, NIRD
SURVEY

BP: 180/100 mmHg, HR: 79, RR: 22, T: 36.4, O2sat: 99%, Wt: 59 kg,
VITAL SIGNS Ht: 152cm, BMI: 25.5kg/m2 (overweight)

Warm to touch, Anicteric sclera, pink palpebral conjunctiva, moist lips

SHEENT and oral mucosa

(-) lesions, (-) masses, (-) neck vein distention; (-) cervical
NECK lymphadenopathy
Physical Examination

CHEST/LUNGS Equal Chest Expansion,clear breath sound on all lung fields.

Adynamic precordium, Distinct S1 and S2, No murmurs, No heaves and

HEART
thrills

soft, non-distended, nontender abdomen, NABS

ABDOMEN (-) Costovertebral angle tenderness(+)presence of big mass on top of
abdomen

Full pulses, full range of motion, CRT <2secs, no edema,no muscle

EXTREMITIES
wasting.
Neurologic Examination
Level of Consciousness: GCS15 Sensory
Orientation: Oriented to person, place, and time 100% on all upper and lower
extremities
Memory: Intact

Motor strength:
Left arm paralysis,left restless leg syndrome
Latest Laboratory Results

Complete Blood Electrolytes PT, APTT

Count
Prothrombin Time
Hgb 116 L Na 138.40 Patient 12.4
INR 1.05
Hct 0.38 L K 5.67 H
% Activity 85.10
RBC 4.39 ICa 1.038 L Control 11.7
WBC 3.3 L Mg 1.07 H
L 0.13 L EGFR: 4 APTT
M 0.08 S. Creatinine 1191.3 H
E 0.12 H Urea 14.96 H APTT 29
Plt 152 Control 29.2
ECG

Heart Rate- 69.2 bpm

Rhythm- regular sinus rhythm
PR - 0.2 s
QRS- 0.06 s
QT - 0.37 s
Impression: Left ventricular
hypertrophy
CHEST X-RAY Exposure Adequate exposure

Expansion Good expansion

View AP

Airway Trachea is deviated to the right

Bone No bone or tissue abnormalities

CT ratio Ct ratio < 0.5

Diaphragm Costophrenic and cardiophrenic angles

are sharp

Infiltrates No infiltrates

Impression Cardiomegaly
 CT-Scan

1. Acute bleed, right external capsule-corona radiata

2. Old lacunar infarct, left lentiform nucleus
3. Cerebral atherosclerosis
4.Mucus retention cyst, right maxillary sinus
CURRENT MANAGEMENT & PLANS

Please admit the patient under the service of Dr. Bad-ang

Secure consent to care
Start venoclysis: PNSS 1L @ KVO rate
Vsq4, I&O qshift CBG now
Diet: No pork, No beef
Plan to do Cranial CT-scan plain as STAT
Give clonidine 150 mg tab SL now
Admitting impression

CVA cerebrovascular accident

End stage renal disease secondary to hypertensive nephrosclerosis’
Stage II HPN
PLANS

Plan to do Cranial CT-scan plain as STAT

Hyperkalemic regimen:
RI 10 U + D5O 1 mg now
Cal. Glu 10% 1:1 slow IU push now
Kalimate sachet, 3 sachets TID X 3 doses 1st dose now
Hook to cardiac monitor
Medications

Amlodipine 10 mg tab OD PO
Clonidine 150 mcg tab BID PO
Trimetazidine 35 mg tab, 1 tab BID PO
Carvedilol 25 mg tab, 1 tab BID PO
Atorvastatin 40 mg tab OD
Entresto 100 mg tab, BID PO
Vitamin B complex tab, 1 tab OD
Ferrous sulfate + FA tab, 1 tab OD
EPO 5000 U SQ 3x a week
Sevelamer 800 mg tab BID
Ketoanalogues tab, 1 tab TID
Referral #1

NAME : Mr. M R
AGE/ SEX. : 64YRS / M
ADDRESS. :DAVAO CITY
RELIGION : RC
MARITAL STATUS : MARRIED
OCCUPATION : RETIRED ELECTRICIAN
WARD : ER
DATE & TIME PERFORMED : 27-FEB-2024, 4.00 PM
Chief Complaint

Abdominal pain
History of Present Illness
Two years PTC patient was on admission for acute gastric ulcer in nearby hospital and treated with omeprazole 20
mg 1 tab thrice a day before meal for 5 days. Since there was a relief of pain, patient stopped taking medications.
Two days PTC, patient had an onset of non radiating dull pain with a pain scale of 5 , over upper middle epigastric
region, associated with fever (not documented). No other associated symptoms like vomiting or loose stools. Patient
was active the whole day. Patient took 3 normal rice meals that day. Since there was no relief with pain patient self
medicated himself with Paracetamol 500mg 1 tab once a day for fever and dicyclomine 20 mg 1 tab before food for
abdominal pain. No relief with pain medication taken, but fever got relieved (temp not documented). No consultation
was taken that day.
One day PTC, patient had an onset of non bloody, non foul smelling loose watery stools for 2 episodes, 50 ml
each episode associated with radiating sharp colicky pain over upper middle epigastric region to right lower quadrant
(pain scale of 6/10), increase in pain with climbing steps. Patient had a loss of appetite, so he took only milk.In the
interim, patient was apparently with no complaints of dysuria, hematuria, and flank pain. Patient also had fatigue. No
medications taken. No consultation was done.
On the day of consultation, patient had an increase in colicky pain over right lower quadrant ( pain scale of 7/10),
Associated with fever (not documented). No medications taken. Since there was no relief with pain, patient prompted to
seek consultation in ER DMSFH in the evening.
PAST MEDICAL HISTORY

No history of hypertension
No history of Diabetes
No history of Asthma
No history of trauma
History of previous hospitalization for acute gastric ulcer before 2 years in a private clinic.
*No maintenance drugs given.
No history of prior surgeries.
 PERSONAL & SOCIAL HISTORY

5 pack year smoker

Non-alcoholic beverage drinker
Denies herbal medications
No chronic NSAID use
FAMILY HISTORY
(+) Hypertension and diabetes for his elder brother.

(-) asthma

(-) cancer
REVIEW OF SYSTEMS

General : (-)Weight loss (+) anorexia

Skin: (-) pruritus, (-) rashes

HEENT: (-) blurring of vision, (-) hearing problem, (-) nasal congestion, (-) sore throat, (-) hoarseness, (-) ear
discharge, (-) sore throat. , dry tongue (+)

Respiratory: (-) dyspnea

Cardiovascular: (-) chest pain, (-) palpitations

Gastrointestinal: (-) diarrhea, (-) constipation, (-) hematochezia, (-) melena,

REVIEW OF SYSTEMS

Renal & Urinary: (-) dysuria, (-) polyuria, (-) hesitancy, (-) urgency

Musculoskeletal: (-) easy fatigability

Hematological: (-) spontaneous bleeding, (-) easy bruising

Endocrine & Metabolic: (-) heat/cold intolerance, (-) excessive sweating

Nervous System: (-) tremors, (-) syncope, (-) headache, (-) dizziness
Physical Examination
GENERAL
Awake, cooperative, conversant, NIRD, in pain, GCS 15
SURVEY

BP: 130/80 mmHg, HR: 100 bpm, RR: 20, T: 37.7 ’c, O2sat: 95% in
VITAL SIGNS R.A..Wt: 65kg,
Ht: 152 cm, BMI: 28.1 kg/m2 (obsese class 1)

(-) rashes, normocephalic head, icteric sclera, pinkish palpebral

SHEENT conjunctiva, nasal septum at midline, dry lips ,no neck engorgement and
oral mucosa, dry tongue.

(-) lesions, (-) masses, (-) neck vein distention; (-) cervical
NECK lymphadenopathy
Physical Examination
Equal chest expansion , resonant, clear breath sounds in all lung fields.
CHEST/LUNGS
No wheezes, no crackles.

PMI @ Left 5TH ICS MCL, Adynamic precordium, Distinct S1 and S2,
HEART
No extra heart sounds. No murmurs, No heaves and thrills

On inspection : No lesions and scars; flat,soft, non distended

On ausculatation : normoactive bowel sounds, no bruits, no rubs.
ABDOMEN On palpation : pain on deep palpation over RLQ, and tenderness
Positive for Rovsing’s and obturator sign
On percussion : dullness to tympanic.

EXTREMITIES Full pulses, full range of motion, CRT <2secs

Laboratory Results

Chemistry CBC
APTT 41.1 H
Hgb 144 PT INR - 1.03
Na 129.50 Hct 0.44
K 3.90 RBC 4.80
iCa 1.054 Plt 111 L
Mg 0.87 Wbc 15.8 H
N 0.93 H
L 0.04 L
M 0.03
E 0.00
B0
ECG

HR - 100 bpm
Rhythm- Regular
Axis- No axis deviation
PR-0.12 s
QRS- 0.08s
QT- 0. 38 s
Impression- Sinus Rhythm
Normal ecg
Working impression
Current management and Plans

IVF to start once on NPO D5NSS 1L at 120cc/hr

VSq4
I&O qshift
Diabetic diet
May have light breakfast tomorrow morning then NPO starting at 5am
THERAPEUTICS

1. Pantoprazole (Pantovex) 40mg IV at 10AM

2. Ceftriaxone + Sulbactam (Trilagram) 1.5gm IV 1hr prior to OR
 PROBLEM LIST
Obstructive uropathy sec to Proximal 3rd Middle 3rd Ureteropelvic junction calculi, right

- For RIRS right tomorrow to follow 12nn RIRS last case

- Plan to clear the pt as RCRI class I risk with a 3.9% risk of MACE:
-Elevated risk surgery 0
-Hx of IHD 0
-Hx of CHF 0
-Hx of CVA 0
-Preop insulin 0
-Preop crea > 178 0
Total 0 point,
class I risk
 PROBLEM LIST
DM II
- Will suggest CBG TID premeals + 11pm 3. R/O ACS
- No noted chest pain, dyspnea, abdominal pain however noted with ECG changes: T wave
inversion at I, AVL
- Will suggest to main service to request for Trop I to rule out ACS
Referral #2

P.S
60/M
Chief Complaint

Icteresia
History of Present Illness

4months PTA, noted onset of icteresia associated with bloatedness. No abdominal pain, nausea or vomiting, fever or
other symptoms. He was advised to do WA USD which revealed gallbladder stone 1.3cm in size. He was advised for
surgery but patient did not immediately comply.

2 weeks PTA, consulted with surgery AP and repeat WA USD revealed

- fatty liver
- Calculous cholecystitis (largest diameter 1.2cm)
- Ureteropelvocaliectasia with lithaises, left

Patient was referred to your service for CP clearance and cleared as OPD. Patient was noted with pyuria on
urinalysis and given Cefuroxime 500mg tablets OD X 7 days. No dysuria or fever during this time.

Patient was then scheduled for lap cholecystectomy tomorrow, hence this admission.
 Past Medical History
(+) Hypertension x 10yrs
-uSBP 130, hSBP 160
-meds: Irbesartan 160mg tab OD, Amlodipine 5mg tab OD

(+) DM x 3 yrs
-FBS 8.51 H
-Linagliptin/metformin 2.5/500 tab BID, Gliclazide 30mg tab OD

(-) BA (-) MI (-) CVA

(+) previous hospitalizations
- more than 5yrs ago for pneumonia

(-) previous surgeries

FAMILY HISTORY

(+) gallbladder disease - siblings

(+) hypertension- mother, siblings
(+) DM - maternal
 Personal/Social History

Previous smoker (80pack years) stopped 3 yrs ago

Previous alcoholic beverage drinker stopped 3 yrs ago
No herbal medications
No Food and drug allergies
Review of Systems
General: (-) fever, (-) chills

Skin: (-) itching,(-)rashes, (-)pruritus, (-) jaundice

HEENT: (-) headache, (-) dizziness, (-) hoarseness, (-) sore throat

Respiratory: (–) dysphagia, (–) hemoptysis

Cardiovascular: (-) palpitation, (+) 1 pillow orthopnea, (-) chest pain, (-)edema, (-)easy
fatigability

Gastrointestinal: (-) melena, (-) hematochezia, (-)changes in stool colour

Review of Systems

Renal & Urinary: (-) urinary frequency, (-) hematuria, (–) dysuria,

Muskuloskeletal: (–) myalgia, (-) joint pains

Hematological: (–) bruises, (–) easy bleeding

Endocrine & Metabolic: (–) heat/cold intolerance, (–) polyuria, (–) polydipsia

Nervous System: (–) numbness, (–) tingling

 Laboratory Results

2/7/24
WA USD
-The liver is normal in size and configuration. External outline is regular and smooth. Liver parenchyma is
homogenous but exhibits increased echogenecity. No focal mass seen. The intrahepatic ducts are not dilated.
The widest diameter of the common duct measures 0.28 cm.

-The gallbladder is well-distended with thickened wall (0.9 cm). There are echogenic foci with posterior sonic
shadwing seen intraluminally the largest measures 1.2 cm(I)(previously 1.3 cm dated 10/27/23}

-The pancreas and spleen are normal in size, exhibiting a homogenous parenchymal echopattern and regular outline.
No focal lesion seen.
2/11/24
CXR - normal chest findings

UA
-light yellow, clear
-negative glucose & protein
-pH 5, spgr 1.030
-WBC 9.49/hpf
-RBC 2.29/hpf
-Epith cells 0.4
-cast 0
-bacteria 5.51
2/12/24
Total bilirubin 11.8 PT 13 vs 12.1
DB 3 INR 1.11
IB 8.8 PTPA 80%

Blood type B+ APTT 27.3 vs 29

CBC HbA1c 7.4 H

Hgb 157
Hct 0.46 BUN 4.72
Rbc 5.52 FBS 8.83 H
WBC 12 H Crea 90.4 egfr 84
N 45
12L ECG- Sinus Tachycardia
L 40
M7
E8H
B0
Plt 209
2/19/24
- Normal left ventricular dimension with normal wall motion and contractility
- Normal left ventricular systolic function, left ventricular ejection fraction of 64%.
- Normal right ventricular systolic function
- Normal left atrium and right atrium
- Structurally normal mitral valve, tricuspid valve, aortic valve and pulmonic valve
- No pericardial effusion nor intracardiac thrombus noted
- Normal pulmonary artery pressure

UA
-yellow, clear
-negative glucose and protein 2/21/24
-pH 6, spgr 1.030 FBS 8.51 H
-WBC 15.16/hpf
-RBC 6.01/hpf
-Epith 0.43
-cast 0
-bacteria 9.11
ECG

HR : 100
Rhythm- Regular
Axis- No deviation
PR- 0.24 seconds
QRS- 0.12 seconds
QT- 0.36 seconds
Impression- Sinus Tachycardia
 Exposure Adequate
Chest X Ray Expansion Good expansion

View AP

Airway Trachea is in midline

Bone No bone abnormalities

CT ratio

Diaphragm

Infiltrates

impression
Problem List and Plans

Type 2 DM
-will give RI rescue doses PRN
-will continue OHAS while on full diet

HCVD
-will continue Irbesartan & Amlodipine
-will monitor BP trends
Referral- 1

A.M
60/F
Chief Complaint

Body Malaise
History of Present Illness

10 years PTA, patient had on & off history of abdominal pain on right lower quadrant
with mild pain and no associated signs & symptoms were noted.

4 months PTA, patient experienced on & off abdominal pain during strenuous activity.
Hence sought consult and was diagnosed and treated for H. Pylori. The patient was
advised to take antibiotics for 2 weeks.

In the interim, the RLQ pain persisted. Patients RLQ persisted and underwent ultrasound
which shows shadow around kidney then requested for CT-Scan which shows renal mass
on right.
ODA, patient experienced on and off abdominal pain which radiated to the back with a
pain scale of 4/10 which prompted admission.
PAST MEDICAL HISTORY
H.Pylori infection: Nov, 2023
Treated with antibiotics
(-) HPN
(-) D.M
(-) B.A
FAMILY HISTORY

Brother (Deceased): Similar symptoms

(-) HPN
(-) DM
PERSONAL & SOCIAL HISTORY

Patient is a non-smoker
Patient is a non-alcoholic
Patient eats regular filipino diet- Rice, Meat, Vegetables
REVIEW OF SYSTEMS

General: (+)weight loss, (-) easy fatigability,(-)loss of appetite

Skin: (-) pruritus, (-) rashes, (-) lumps

HEENT: (-) blurring of vision, (-) hearing problem, (-) nasal congestion, (-) sore throat

Respiratory: (-) dyspnea

Cardiovascular: (-) chest pain, (-) palpitations

Gastrointestinal: (-) diarrhea, (-) constipation, (-) hematochezia, (-) melena

REVIEW OF SYSTEMS

Renal & Urinary: (-) dysuria, (-) polyuria, (-) hesitancy, (-) urgency,(-) orange coloured urine

Musculoskeletal: (-) myalgia, (-) arthralgia

Hematological: (-) spontaneous bleeding, (-) easy bruising

Endocrine & Metabolic: (-) heat/cold intolerance, (-) excessive sweating

Nervous System: (-) tremor

Physical Examination

GENERAL
Awake, Alert, Not in respiratory distress
SURVEY

BP: 140/98 mmhg, HR: 103 bpm, RR: 20 bpm, T: 36.8, O2 sat: 98%
VITAL SIGNS
Wt: 47 kg, Ht: 157 cm, BMI: 19.1

(-) Rash, (-) Peteiache, Anicteric sclerae, pink palpabral conjunctiva,

SHEENT
Dilated pupils, Nasal septum in midline, Normocephalic

NECK (-) CLAD

Physical Examination

CHEST/LUNGS Equal Chest Expansion, Clear breath sounds

Adynamic precordium, Distinct S1 and S2, No murmurs, No heaves and

HEART
thrills

No lesions and scars; flat, soft, non-distended;normoactive bowel sounds,

ABDOMEN
(+) Kidney punch sign,

Full pulses, full range of motion, CRT <2secs, no edema,no muscle

EXTREMITIES
wasting.
Laboratory Results Chemistry

Complete Blood Na 134.20 (L)

Count K 4.32
iCa 1.064 L
Hgb 99 (L) CBG-146 Mg 0.84
Hct 0.32 (L) Cre 101
RBC 3.59 (L)
WBC 7.8
N 0.78 H
L 0.13 L
M 0.08
E 0.01
B 0.00
Plt 341
CT-Scan

● Right renal mass with features suggestive of renal cell cancer (RCC), with perirenal fat
● Invasion, hyperenhancing hepatic and bilateral pulmonary metastases.
● Enhancing left retroperitoneal nodule. Consider adrenal metastasis.
● Renal cortical cyst, left (Bosniak I).
● Tumoral thrombosis in the right renal vein extending to inferior vena cava down to bilateral iliac veins.
● Suspicious thrombosis in the main portal, splenic and superior mesenteric veins.
● Ascending colonic bowel wall thickening. Infiltration of right renal mass vs synchronous tumor,
Colonoscopy suggested for further evaluation.
● Consider cystitis
● Thoracolumbar spondylosis
● Vacuum phenomenon, L5-S1
Ultrasound

● Complex Renal Mass, right. contrast-enhanced ct correlation suggested for further

evaluation.
● Suggestive tumor thrombosis, inferior vena cava.
● Gallbladder polyps
● Ultrasonically unremarkable liver, biliary tree, pancreas, spleen, abdominal aorta,
para-aortic areas, left kidney, urinary bladder and prostate gland.
 Exposure Adequate exposure
CXR Expansion Good expansion

View AP

Airway Trachea is at the midline

Bone No bone or tissue abnormalities

CT ratio Ct ratio > 0.6

Diaphragm sharp costophrenic angles

Effusions No effusion

Foreign bodies No foreign bodies seen

Hila & Mediastinum No hilar enlargement or nodules noted

Impression Unremarkable chest findings

ECG
HR - 93.6
Rhythm- regular sinus rhythm
PR- 0.18s
QRS- 0.05s
QT- 0.34
Impression- normal sinus rhythm
Working impression

Right Renal Mass

Probably malignant
Management

● Please admit under the service of Dr. Espino

● Secure consent to care
● DAT
● Monitor VSq4
● Monitor I&O qshift
● Schedule for radical nephrectomy right with IVC Thrombectomy
Medication

● Tranexamic acid 500 mg po TID RTC1, next @ 8 pm. Shift to tranexamic acid 500
mg IV once NPO
● Omeprazole 40 mg IV @ 5 am on 15th Feb, 2024
● Metoclopramid 10 mg IV @ 5 am on 15th Feb, 2024
● Bactidol gargle 3 X @ 6:30 am on 15th Feb, 2024
PLANS

For radical nephrectomy R with IVC thrombectomy

Plan to risk patient as Class I

Risk or 3.8% of MACE

Elevated risk of procedure- 0

Hx of CHF- 0
Hx of CVD- 0
Hx of IHD- 0

Give calcium gluconate 10% 1:1 dilution via SIVP

Facilitate movements of blood products
Referal #2

M.M
65/F
 Chief Complaint

PAIN AND SWELLING IN THE RIGHT HIP

HISTORY OF PRESENT ILLNESS

2 Days PTA the patient fell from the hight of 3 stairs while opening the sliding door
sideways with the left arm on the concrete with bruise in the right side of the fore head ,
bruise in the left thumb and landed on her right hip causing pain and swelling . the patient
had mefenamic acid 500mg TID for relief by the doctor

1 day PTA the patient consulted local clinic in davao oriental and advised to have an X
RAY which revealed hip fracture .they referred them to orthopedics doctor(dr Moreals )
and doctor suggested to have their treatment in dmsf

On the day of admission the patient was scheduled to OR

PAST MEDICAL HISTORY

(+) surgery- appendectomy 1980

Ovarian myoma TABSO procedure 2004
(-)hospitalization
(+)HPN
(+)Allergy for chicken
FAMILY HISTORY

(+)HPN - Father
(+) Cancer- sister breast cancer
 PERSONAL AND SOCIAL HISTORY
Pt is a house wife
(-) smoker
(-)alcohol consumption
Diet - rice, meat, egg, veggies
REVIEW OF SYSTEMS
General: (-) fever, (-) weight loss

Skin: (-) itching,(-)rashes

HEENT: (-) blurred vision, (-) headache, (-) tinnitus, (–) dysphagia, (–) sore throat

Respiratory: (–) cough, (–) hemoptysis

Cardiovascular: (-) palpitation, (-) orthopnea

Gastrointestinal: (-) epigastric pain, (-) changes in bowel habits

REVIEW OF SYSTEMS
Renal & Urinary: (-) urinary frequency, (-) hematuria, (–) dysuria,

Muskuloskeletal: (–) myalgia, (-) joint pains

Hematological: (–) bruises, (–) easy bleeding

Endocrine & Metabolic: (–) heat/cold intolerance, (–) polyuria, (–) polydipsia

Nervous System: (–) numbness, (–) tingling

 PHYSICAL EXAMINATION

GENERAL SURVEY Awake, Alert, NIRD

VITAL SIGNS BP 130/80, HR 85, RR 21, T 36.5, HT- 5’5, WT-65KG BMI-23.9

Anicteric sclerae, pale palpebral conjunctiva, pupils reactive to light,

HEENT
moist oral mucosa , (+) bruise in the left side of the forehead

NECK (-)CLAD

CHEST Equal chest expansion, clear breath sounds, (-)wheezing, (-)crackles

HEART Adynamic precordium, distinct heart sounds, (-)murmurs

PHYSICAL EXAMINATION

Flabby, soft, normoactive bowel sounds , no tenderness on

ABDOMEN
palpation

EXTREMITIES Warm to touch, crt<2secs, edema in left thumb with bruising

 cranial Nerves:

Neurologic exam I: able to smell coffee and soap

II, III: pupils are equally round and reactive to

Level of Consciousness: Awake, coherent(GCS15) light

III, IV, V: able to follow finger superiorly,

Orientation: Oriented to person, place, and time inferiorly, laterally, and obliquely

Memory: Intact V: able to firmly clench and move jaws side

to side
Motor strength VII: no facial asymmetry, able to raise
5/5 on all upper and lower LEFT extremities eyebrows, smile, frown
1/5 on all upper and lower RIGHT extremities
VIII: able to hear without difficulty
Sensory IX, X: able to swallow
100% on all upper and lower extremities.
XI: able to shrug against resistance

XII: able to protrude tongue without deviation

ECG
Rate: 87bpm
Rhythm:
PR interval: s
QRS complex: s
QT interval: s
ST segment:
Exposure Adequate exposure

Expansion Good expansion

View AP

Airway Trachea is at the midline

Bone No bone or tissue abnormalities

CT ratio Ct ratio <0.5

Diaphragm sharp costophrenic and cardiophrenic

angles

Effusions No effusion

Foreign bodies No foreign bodies seen

Hila & Mediastinum No hilar enlargement or nodules noted

Impression Unremarkable chest findings

WORKING IMPRESSION

Right sided hip fracture

CURRENT MANAGEMENT AND PLAN

Partial hip replacement

MEDICATIONS

1. Amlodipine 10mg losartan 50 mg

2. Vital c
3. Bcomplex
REFERAL #3

A.B
64/M
CHIEF COMPLAINT

Hematochezia
HISTORY OF PRESENT ILLNESS
Patient is a known case of Choledocholithiasis
4 Months prior to admission , the patient had the symptoms of bloating, loss of appetite,
intermittent crampy abdominal pain in RUQ, epigastric region, radiating to LUQ and
back associated with diarrhea and constipation. Sought consult at SPMC upon which
labs were done USD:Choledocholithiasis, prescribed with unrecalled meds with
temporary relief. Patient claimed that he was having vomiting, dizziness after taking
meds upon which he discontinued meds. In the interim patient tolerated the condition
and symptoms persisted.
HISTORY OF PRESENT ILLNESS

2 weeks PTA, the above symptoms persisted and was scheduled for cholecystectomy but
was not cleared for surgery due to high levels of creatinine and uric acid and was
prescribed with ketoanalogues 500mg 2tabs TID for 15 days, sodium bicarbonate 650mg
1tab, TID for 15 days but was not compliant due to vomiting after taking meds to be
claimed as side effect by the patient.
In the interim symptoms persisted

5 hrs prior to admission, still persistent with above symptoms now associated with
hematochezia with an amount of blood more than half a glass, and pain localizing more
on epigastric region and RUQ upon which he decided to get admitted, hence the
admission.
PAST MEDICAL HISTORY

(-) BA
(+) HTN- since 2010 (amlodipine 10mg OD)
(-)Hospitalization
(+)Surgical history of cataract surgery in march 2023
(-) unrecalled drug allergies.
Claiming to have gall stones since 1998 without any symptoms , diagnostic reports and
lab reports
FAMILY HISTORY

(-) HPN
(+) heart failure- father
(-) Asthma
(+) DM- mother
PERSONAL AND SOCIAL HISTORY

● Occasional Alcoholic beverage drinker

● Smoking history of 40 pack years from 20yrs old to 64 yrs old
● No Substance use
REVIEW OF SYSTEMS
General: (-) Fatigue, (-) Weight Changes
Head: (-) headache, (+) dizziness, (-) lightheadedness
Skin: (-) Erythema, (+) Rashes, (-) Itching (-) Cyanosis
Eyes: (-) Blurring of vision, (-) redness, (-) Diplopia
Ears: (-) Tinnitus, (-) Otalgia, (-) Discharge
Nose: (-) Epistaxis, (-) Sinusitis, (-) Congestion
Mouth & Throat: (-) Dysphagia, (-) Masses, (-) Odynophagia
Neck: (-) stiffness of neck pain
Respiratory: (-) Cough, (-) Hemoptysis
REVIEW OF SYSTEMS
Cardiovascular: (-) Orthopnea,
Gastrointestinal: (-) Diarrhea, (-) Abdominal Pain, (-) Hematemesis, (-) Hematochezia, (-)
Melena
Renal and Urinary: (-) Dysuria, (-) Hematuria, (-) Flank Pain
Genital: (-) Dyspareunia, (-) Discharge, (-) Pain
Musculoskeletal: (-) Myalgia, (-) Arthralgia
Hematological: (-) Anemia, (-) Easy bruising
Endocrine and Metabolic: (-) Heat/cold intolerance
Nervous system: (-) numbness, (-) seizures
PHYSICAL EXAMINATION
GENERAL Awake, alert, conscious, not respiratory distress
SURVEY

BP 120/80, HR 91, RR 20, T 34.5, Wt 71.5 kg, Ht. 5’5

VITAL SIGNS
BMI:25

Pupil are equally round and reactive to light and

HEENT accommodation, Anicteric sclerae, pink palpebral conjunctiva,
no sinus tender, No ear discharge,

NECK No mass, no scars, no lumps, no lymphadenopathy.

Equal chest expansion, clear breath sounds, no wheezing, no

crackles, equal tactile fremitus,
CHEST
, Adynamic precordium, distinct S1 & S2, no S3 & S4 noted, no
murmur, no heaves and thrills
PHYSICAL EXAMINATION

Hard , distended abdomen , (+) tenderness at epigastric and

ABDOMEN RUQ upon palpation , high pitched and irregular hyperactive
bowel sounds

Warm, Full range of motion, no muscular atrophy, no muscular

EXTREMITIES
weakness, full pulses,

GENITALIA
PHYSICAL EXAMINATION

NEUROLOGIC EXAM
Level of Consciousness: GCS 15
Orientation: Oriented to space, time, and person
Memory: Able to recall past, recent, and immediate memories
Cranial Nerves: Intact Cranial Nerves
Motor strength: 5/5 on both upper and lower extremities.
SALIENT FEATURES

● 4 months of
● RUQ, epigastric and LUQ crampy pain
● Alternating diarrhea and constipation
● Distended abdomen due to bloating
● Loss of appetite
● History of choledocholithiasis
● Hematochezia on the day of admission
 Differential diagnosis
Colorectal carcinoma

RULE IN RULE OUT

Change in bowel habits No significant detail to rule out

Rectal bleeding
Abdominal pain
Bloating
Poor apetite
Unexplained anemia
Risk factors for colorectal carcinoma
Patient’s age is more than 50 ( 64 yr)
Has smoked sigrrates for more than 35
years ( 40 pack years)
 Differential Diagnosis
MECKELS’ DIVERTICULUM

RULE IN RULE OUT

(+)Melena (-)Poor appetite not a major symptom of
(+)Diarrhea diverticulitis
(+) (-) fever
(-) most commonly left sided abdominal region

UlCERATIVE COLITIS RULE OUT

RULE IN (-)bloating
(+) Change in bowel habits (-)poor appetite
(+)abdominal pain (-)fever
(+) hematochezia
Laboratory Results
Chemistry
Complete Blood Count
Hgb 94 (L) Na- 135.30
Hct 0.30(L) K- 6.26(H)
RBC 2.95(L) iCa- 1.144
WBC 12.5 (H) Mg 0.90
N 0.83 (H)
L 0.09 (L) Crea 595.5(HH)
M 07 Urea: 27.68 (H)
E 01
B0 PT 13.7 secs
Plt 131 (L) INR 1.17(H)
%ACTIVITY 74.7
Control 11.7 secs
APTT 33.4 secs (H)
Control 29 secs
ECG
Rate: 84bpm
Rhythm: regular sinus rythm
Axis deviation : normal 60
degree axis
PR 0.12s
QRS 0.08s
QT 0.36s
Impression- normal sinus
rhythm
 Exposure Adequate exposure

Upright chest X RAY Expansion Good expansion

View AP

Airway Trachea is at the midline

Bone No bone or tissue abnormalities

CT ratio Ct ratio <0.5

Diaphragm sharp costophrenic and

cardiophrenic angles

Effusions No effusion

Foreign bodies No foreign bodies seen

Hila & No hilar enlargement or nodules

Mediastinum noted

Impression Unremarkable chest findings

WORKING IMPRESSION

● Coagulation disorders secondary to increased APTT and INR

● Symptoms suggestive of colorectal carcinoma
CURRENT MANAGEMENT AND PLAN

-IVF D5NSS 1L @100cc/hr

-Low salt, low fat diet
-VSq4 hrs
-I/O qshift
-CBG now then q4hrs while on NPO

-PLAN
-Upper and lower GI endoscopy
MEDICATIONS

1. Amlodipine 10mg OD
2. Tranexamic acid 500mg IVTT q8
3. Pantoprazole 40mg IVTT now then OD AC

-hyperkalemic regimen:
4. Kalimate sachet 3 sachets PO TID 3doses
5. RI 10 U + 1amp D50W now
6. Calgluc 102 1:1 IV push
Plan

-For repeat serum K tomorrow 5am

-Secure 1 U PRBC of patients blood type