Usth Department of Physical Medicine and Rehabilitation

;USTH DEPARTMENT OF PHYSICAL MEDICINE AND REHABILITATION

January 16, 2010 (Saturday)

CLINICAL DIVISION

Total In-patient: 20 Admission: 0 New Referrals: 3 Mortality: 0 Transfers: 0 DAMA: 0 Sign-out: 0 Discharges: 0

Room / Name/Age/Sex / Diagnosis / OT/PT Notes / Remarks
MALE SURGERY
309E
GS
PllasticSx
Pedia-Infectious
ENT
DOA: 11/23/09
DOR: 01/04/10 / ELIA, Jans Anthony 6M
Bldg 19 Rm 118 Katuparan Vitas, Tondo, Manila / Deconditioned Syndrome;
Multiple lacerations and avulsion of R malar region of face s/p debridement and full thickness skin grafting; fracture open Type IIIB complete transverse displaced, surgical neck humerus L avulsion injury w/ bone and soft tissue exposure s/p debridement, s/p ORIF L proximal humerus / PT: refused
Prev. PT (1/13): Bike ergo x 10 mins, amb around center and stair neg with CGA+1 @back x 2 rounds; parallel bar ex (squats, high marches) c frequent rest periods
PR 84-95 bpm / 12/20 wound culture: Pseudomonas aeruginosa heavy growth. Sensitive to: Amikacin, Gentamycin, Ceftazidime, Piperacillin-Tazobactam, Cefepime, Tobramycin. Intermediate to: Imipenem, Aztreonam
Resistant to: None
12/29 UA Color: Dark yellow, Transparency: Turbid, pH6.5, SG 1.020 Albumin (-), Sug (-), Pus 0-2/hpf, Bact (+), AU++++, MT ++++
12/31 CBC Hgb 105, Hct 0.32, Plt 500, WBC 5.30, Neutro 0.54, Lympho 45 Mono 0.01
BUN 13.4, Crea 0.28
Wound Culture: Acinetobacter baumannii heavy growth. Sensitive to: none. Intermediate to: inocycline
Resistant to: Amikacin, Ceftriaxone, Ceftazidime, Cefepime, Imipenem, Tobramycin, Gentamycin, TMP-Sulfamethoxazole, Sulbactam-Ampicillin, Piperacillin-Tazobactam
1/4 SGPT 35.3
1/6 X Ray l humerus: the L humerus as seen through cast shows orthopedic pins fixing the fracture at the proximal humerus. The fracture is in adequate alignment. Fracture line is still appreciated / Paracetamol
Ciprofloxacin
311C
Pulmo
Endo
CV
Anes
Ortho
DOA: 12/27/09
DOR: 01/06/09 / HABEL, Modesto Labadias
68/M
1269C Francisco St., Bgy Kasilawan, Makati City / Fracture closed, complete, impacted suboccipital area – femoral neck – R (12/25/09) s/p partial hip replacement, R (Austin Moore, cemented) (01/04/10)
HPN St. 2
DM type 2, uncontrolled
Bronchial Asthma / PT: standing inside parallel bars x 11’ NWB on RLE, min +2 assist @ back & RLE, d/c d/t fatigue
BP 130140/70 / 12/30 Choles 159 Trig 107 HDL 30.9 LDL 103
12/31 2D Echo w/ Doppler: 1. Concentric LVH w/ segmental wall abnormality, preserved systolic function and Grade 1, 2. Top normal left atrium, 3. Tricuspid regurgitation, mild diastolic function (impaired relaxation), 4. Aortic regurgitation, mild
1/5 Na 134 K 4.3
1/6 Tot CHON 4.4 Alb 2.6 Glob 1.8 A/G 1.4
U/A: lt, yellow, sl. Turbid, pH 5, sg 1.030, alb +, sug +=+, RBC 75-80/hpf, pus 20-25/hpf, bacteria +++, mucus ++, uric acid +++
1/6 X ray both hips: ff up exam shows R hip prosthesis in place, alignment of hip prosthesis is satisfactory
1/6 CXR: Cardiomegaly, Atheromatous Aorta
1/11 Hgb 121, Hct 0.36, Plt 402, WBC 19.0, Seg 0.93, Lympho 0.05, Mono 0.02
U/A Lt yellow, clear, pH 7.0, sp gr 1.005, Alb -, Sugar -, RBC 0-2, Pus 0-2
Crea 0.89, Na 135, K 3.8
1/14 Hgb 122 Hct 0.36 plt 344 WBC 13.8 bands 0.01 segm 0.80 lympho 0.17 eosino 0.02 / Seretide, Moexepril, Amlodipine, Simvastatin, Lactulose, Trimetazidine, Salbutamol, Dolcet, Arcoxia, Enoxaparine, Prednisone, Ciprofloxacin, Salbutamol, Metformin, Protis
311H
DOA: 1/11/10
DOR: 1/15/10 / BONDOC, Arcadio
76/M
1471 Blumentritt st. Sampaloc, Manila / 1/11 ECG: Primary AV Block; Left anterior fascicular block; Left atrial AB; LVH by Cornell; Poor R-wave progression V1-V3; Non-specific ST-T wave changes.
CXR- Cardiomegaly w/ LVH; Atheromatous aorta; Incidental dextroscoliosis thoracic spine
PT 11.7, aPTT 29.8
U/A- yellow, slightly turbid, pH 5, sp gr 1.015, Alb -, Sugar -, RBC 10-15, Pus 1-3, Bacteria few
Hgb 145, Hct 0.43, Plt 277, WBC 9.7, Seg 0.80, Lympho 0.20, ABO A+
Na 134, K 3.7, Crea 1.00
11/12 Hgb 114, Hct 0.34, Plr 247,WBC 8.10, Seg 0.70, Lympho 0.29, Mono 0.01
Na 142, K 4.3
1/13 Yellow, slightly turbid, pH 5, sp gr 1.020, Alb – Sugar +, RBC 5-10, Pus 0-2, Bac +
1/15 Crea 0.96, Na 139, K 3.3 / Mannitol
Paracetamol
Celecoxib
Amlodipine
Clonidine
Citicholine
Co-Amoxyclav
313 L
ADMISSION
CV
Endo
Neuro
DOA: 01/04/09 / ALCAZAR, Rendo
36/M
Luksuhin , Ibaba, Alfonso, Cavite / s/p R cerebral infarct (7/12/09) with post stroke seizures
s/p fracture L forearm s/p ORIF (2000)
subglottic stenosis
s/p change of tracheostomy
HPN prob 20 to hyperaldosteronism, pheochromocytoma, renal artery stenosis
ASHD, CAD, s/p arrest sinus bradycardia, NIF, NYH 4, Class IIB; DM type II controlled / PT: ambulation on level surface w/ quad cane ~ 35 m without rest periods; bike ergo x 3’ d/c d/t BP 80/50
BP 80-100/50-60 mmHg
IOT: tolerated standing fr sitting with propping on table; balancing tasks / 1/4 crea 0.69 Na 138, K 3.4
1/5 Hba1c 5.9
ECG: sinus bradycardia, LVH, anterolateral wall ischemia
1/6 UTZ of KUB with resistive : hydronephrosis grade III to IV with nephroliathiasis left. Normal sized kidneys with slight renal parenchymal disease, bilateral, mildly elevated resistive, moderate urinary retention.
1/8 Na 137, K 4.1
1/9 s/p Flexible Tracheoscopy (+) mucous plug- 40% of lumen on distal end of the tracheostomy tube, clear at the level of the carina
1/13 Na 135 K 3.2 / Simvastatin, Clonidine, Amlodipine, Metoprolol, Phenobarbital, Lactulose, Apresolin, Losartan, Spironolactone,
Kalium durule, Lantus
Female Surgery
310D
ID, Neuro, CV,Nephro, Pulmo, Endo
Ortho, Optha
Derma
DOA: 11/26/09
DOR: / SALTING, Adela Lopez 95/F
Tondo Manila
MGH / Closed complete comminuted displaced intertrochanteric area right femur s/p hip screw fixation 12/23/09 / PT: deferred d/t K 2.9, Na 132
Prev PT(01/14/10): standing between parallel bars NWB on R LE x 3’, d/c d/t dizziness and decrease BP 80/60 from 100/60; after 5’ of rest BP 110/60
BP 110-120/60-70
PR 62-67 / CXR: cardiomegaly; elevated right hemidiaphragm atheromatous aorta; hip xray: there is a comminuted intertrochanteric fracture at the right proximal femur and superolateral displacement of the right femoral neck;
12/8 ECG: SR, occasional PVCs, L anterior facicular block, NSSTWC
12/23 Xray of hip: R hip prosthesis is seen graversing the fractured segments on the R femur
12/27 CBC hgb 105 Hct 0.31 Plt 247 WBC 7.1 seg 0.49 lymph 0.47 eo 0.04
12/28 U/A yellow, sl.turbid, ph 7, sg 1.010 A/S (-), RBC 0-2 pus 2-4 yeast ++ sq + Bact few
1/2 Na 123 K 3.9
1/8 Na 125, K 4.0
1/13: Na 137 K 3.3, Crea 0.43
Na 132, K 2.9, Mg 1.6, iCa1 1.17
Hgb 104, Hct 0.31, Plt 259, WBC 6.7, Seg 0.45, Lympho 0.51, Eos 0.04 / Dolcet,Tramadol
Amlodipine, Metoprolol
Trimetazidine
Calvit,Humalog, KmNO4, Metformin
Benzoyl peroxide,
KmnO4 compress,
Protos sachet
PEDIA
320C
PediaHema
DOA: 1/11/10
DOR: 1/13/10 / ORDONEZ, James
10/M
#30 Aurora Drive, Verzon Ville, Subdivision, Las Pinas / Hemophilia A, severe with inhibitor / PT: amb around center w/ BAC x 2 rounds w/ CGA, able to negotiate 1 flight of high step stairs, 25 % WB w/ BAC
No VS / 1/11 aPTT 114.3 NC 35.0 aPTT at 1:1 dilution 44.8 aPTT at 1:1 diluetion after 1 hour dilution 71.6
PT 13.1 NC 12.88 PT ratio 1.1 INR 1.1
Hgb 121 Hct 37 plt 631 WBC 8.7 segm 69 lympho 30 eosino 1 / FEIBA
322J
Neuro Sx
Ped Cardio
Pedia Hema
Pedia Cardio
DOA: 12/26/09
DOR: 1/12/10 / ENCARNACION, Denol
13/M
Blk 63 Lot 42 Marycris Complex Gen Trias, Cavite / Hemophilia B, mild
Subdural hematoma, L frontal convexity (Dec 2009, July 2009) / PT: No notes
Prev PT(01/14/10): amb at b/s x 6 meters CGA, clinical restorator x 10’
BP 120-130/70
PR 95 / 12/26 Cranial CT: Hyperacute to acute lobulated extra-axial hematoma formation that can be due to confluent epidural and subdural hematoma formations in the left frontotemporal convexity exhibiting mass effect, as described, resolution of right frontal epidural hematoma and subarachnoid hemorrhage from previous study. Incidental mucoperiosteal thickening in the left maxillary sinus
12/30 Cranial CT: Acute lobulated extra-axial hematoma w/ no significant change in contour and mass effect in the left frontoparietal convexity
1/4 Hgb 108, Hct 0.31, Plt 348, WBC 10.20, Seg 0.85, Lympho 0.13, Eos 0.02
1/8 Cranial CT: Interval decrease in size and density of the subdural hematoma in the left parietal region
1/9 U/A: Yellow, sl turbid, pH 8, sp gr 1.015, Albumin 2+, Sugar -, RBC 8-12, Pus 0-2, Bacteria- few, AU- few
1/10 BUN 15.6, Crea 0.67 / Paracetamol, Phenytoin, Etoricoxib
Diphenhydramin
Zonisamide
Amlodipine
MEDICINE FORBES
205H
Pulmo
Nephro
Neuro
Rheuma
DOA: 12/03/09
DOR:
12/17/09 / Cruz, Rosie Nudo
57/F
San Jose Del Monte, Bulacan
MGH
For Home PT / Deconditioned syndrome
SLE not in flare
HAP, resolving
Decubitus ulcer, sacral area, resolving
s/p tracheostomy / PT: refused
Prev. PT (01/06/10): w/c sit x 30min
BP: 120/80
Still for IOT / 11/11 TSH 3.36, FT3 2, FT4 15
11/14 FOBT (-)
12/8 PT 14.3, NC 12.8, INR 1.2, apt 39, NC 36.0
12/16 Crea 1.3, Na 137, K 3.7, iCa 1.17
12/18 Fecalysis, brown, mushy, yeast ++, fat globule ++, mucus +, parasite none
12/26 BUN 12.5 crea .76 Na 138 K 4.1
12/28 CBC Hgb 132 Hct 0.39 Plt 298 Wbc 27.4 seg 0.81 lymph 0.19 U/A dk yellow, sl. Turbid, pH 6, sg 1.015, A/S (-), Rbc 0-3 pus 10-15, yeast +, sq. +, renal cell +, bact few, AU +
PT 12 NC 12.8 PT ratio 1 INR 1 Aptt 30.6 NC 36
1/8 UA dark yellow, sl turbid, pH 5.0, SG 1.020, Alb +, Sug +, RBC 1-3, pus 6-10, yeast few, sq cell feew, trans epith few, bact few, MT ++, AU +
1/12Urine C and S- no growth after 2 days
1/14 Hgb 126 Hct 0.40 plt 391 WBC 15.6 segm 0.81 lympho 0.19 / Folic acid, INH+R, Hexetidine mouthwash, EPO, KMnO4, PZA, Metoprolol, Omeprzole, Diltiazem, Clonidine, Zinc oxide, Imipramide, Paracetamol, Ciprofloxacin, Prednisone
211A
CV
Nephro
Neuro
GI
IR
Ophtha
DOA: 12/31/09
DOR: 1/8/10 / AQUINO, Ma. Paz Austria
68/F
502 Amarlanhagui St., Tdo Manila / CVD infarct left subinsular (1/6/10)
Hyponatremia prob salt losing nephropathy vs diuretic use
AKI due to infection w/ CKD 20 to DM nephropathy
Complicated UTI
DM type 2
ASHD CAD NIF Class IIIC / Still for IPT / 1/3 crea 4.4, Na 138, K 4.3
1/4 CBC hgb 127, hct 0.36, plt 200, WBC 7.8, neutro .50, lympho .43, eo 0.07
1/6 Cranial CT: lacunar infarct L subinsular area; old infarct L corona radiata, w/ associated asymmetric dilatation of the frontal horn and body of the L ventricle; cerebro-cerebellar atrophy; partial cavum septum pellucidum
1/8 BUN 51.4, crea 3.9, Na 136, K3.4; CBC: hgb 123, hct 0.37, plt 240, WBC 9, neutro .65, lympho .29, eo 0.06
1/10: CXR : Ff-up film compared to the oone done on 1/4/10 shows slight resolution of the densities over the right mid and lower lung areas. The rest of the chest findings remain unchanged.
1/11 occult blood (+)
1/12: CBC: hgb 111 hct .34 Plt 282 WBC 12.9 Seg .69 Lympho .26 Mono .02 Eos .03
PT 15.4 N 12.6 aPTT 54.1 n 35.5 / Trimetazidine
NaHCO3
ISDN, ISMN
Pregabalin
Levofloxacin
EPO, Citicoline,
Clopidogrel
Lactulose, Fluimucil
Sitagleptin, Calmoseptine, Atorvastatin, Folic Acid, Pantoprazole,
Enoxaparine
211C
Endo
ID
Rheuma
GI
Dietary
Ophtha
Neuro
DOA: 12/28/09
DOR: 1/11/10 / OMAYANA, Elena
40/F
10 BPI compound Visayas St., Quezon City / t/c Transverse Myelitis Sensory Level T4 Asia B
DKA
CAP immunocompromised
DM type2, poorly controlled / PT: refused d/t financial constraints
Prev PT (1/12): GBRE @ 60 deg x 30 mins; d/c d/t pain on low back area’
BP: 120/70 mm Hg / 12/16 CXR: Consider the possibility of pleural effusion, right with compressive atelectasis
Suggest sonographic correlation. A concomitant pulmonary congestion on the left cannot be ruled out.
12/17 CXR: There is increase in the transverse diameter of the heart.
There is pulmonary congestion. Pleural effusion is seen bilaterally, more on the right side
ET tube inserted with its tip at the level of T2;ECG: Sinus Rhythm, Anterolateral Wall Ischemia, Persistent Posterobasal Forces, Low Voltage in the Limb Lids
12/18 UTZ of Right hemithorax: There is a right pleural effusion measuring 10.5 x 7.1 x 10.7 (AP x W x L) with an approx. volume of 418cc. An incomplete septa is appreciated
12/27 Hgb 134 , Hct 0.40, Plt 383 ,WBC 11.40 ,Seg 0.78, Bands 0.08, Lympho 0.14
U/A: Yellow, turbid, 5.0, 1.015, Alb +, Sugar ++++, RBC 20-25, Pus 4-8, Bacteria +, AU +, Squamous cells ++++; BUN 14.2, Crea 0.50, Hba1c 10.9, SGPT 181, Na 127, K 4.1, Cl 84, Acetone positive
ABG pH 7.442, pCO2 27.1, pO2 227.3, FiO2 32, HCO3 18.5; ECG: Sinus tachycardia
Gram stain: Grams Stain ETA; No microorganism seen; Polymorphonuclear Leukocytes +++
Squamous Epithelial Cells – Few
12/28 CXR: AP supine chest shows slight increase in the transverse diameter of the heart. There is accentuation of the pulmonary vascular markings, which could be positional in nature. Opacities are seen in the left base. To rule out pneumonia. Diaphragm is elevated. Both sulci are intact.
1/2 CXR: ACCENTUATED BASAL PULMONARY MARKINGS MAY BE POSITIONAL, HOWEVER, PNEUMONIA CANNOT BE RULED OUT. BORDERLINE CARDIOMEGALY.
PLEURAL EFFUSION AND/OR THICKENING
1/4 Cervical Xray: There is straightening of the cervical spine, probably due to muscular spasm
MRI of cervical and thoracic w/ contrast: CONSIDER CELLULITIS/MYOSITIS OR NON-SPECIFIC SOFT TISSUE INFLAMMATION AT THE POSTERIOR PARASPINAL REGION, C3 TO T2 LEVEL.DISK DEGENERATIVE CHANGES OF THE CERVICAL SPINE, AS DESCRIBED, WITH CERVICAL STRAIGHTENING WHICH MAY BE DUE TO MUSCLE SPASM.