9A HAND OFF COMMUNICATION FORM

JUNE 22, 2024

901 PURUGANAN, GLECY BUNUA SURGERY
902 SY, GLADYS SURGERY
903 YAP, ISMAEL 69/M REF PORT-SITE INFECTION, PELVIC JUNE 21 JUNE 19 6/20 PIPERACILLIN TAZOBACTAM PENDING
REF 6/21 LANTONIO – MRA AT ABSCESS SECONDARY TO ICA 1.07 (1.01) 4.5G IV Q6 CBC, NA, K, MG
ER>>OR OR; CO-MGT RUPTURED DIVERTICULITIS, MG 0.70 NA 140 K 3.7 CHEST X-RAY PARECOXIB 40MG IV Q13 X 2 DOSES
CC: PERIUMBILICAL LEAK AND ERYTHEMA HINCHEY II PRESENT EXAMINATION SINCE THE 23 MAY 2024 STUDY PANTOPRAZOLE 40MG IV OD DIET: CLEAR LIQUIDS
EJERCITO (SURGERY) S/P LAPAROSCPIC WOUND GS AGAIN SHOWS NO ACTIVE INFILTRATES IN BOTH TRAMADOL 50MG IV Q8 PRN FOR IVF: D5NR 1L X 8HRS
HPI: CHOLECYSTECTOMY 10-25 POLYMORPHONUCLEAR CELLS LUNGS.PULMONARY VASCULARITY IS NO LONGER SEVERE PAON O2: RA
CASE OF A KNOWN HYPERTENSIVE, DYSLIPIDEMIC, AF IN <10 EPI CLLS ACCENTUATED. CONSIDER RESOLUTION OF MILD ENTRESTO
CVR, FOR 10-15 YRS, DM, NON INSULIN REQUIRING, WHO 1+ GRAM POSITIVE COCCI PULMONARY CONGESTIVE CHANGES. PLEASE SPIRINOLACTONE 20MEQS KCL IN 200NSS IV X
CAME IN DUE TO PERIUMBILICAL LEAK. S/P DIAGNOSTIC 1+ GRAM NEGATIVE RODS CORRELATE CLINICALLY.THE HEART IS ENLARGED.THE 2 HRS X 3 CYCLES
LAPAROSCOPY AND AORTA IS PARTLY CALCIFIED.THE BILATERAL DC:
IN MAY 12, 2024 PATIENT WAS KNOWN TO HAVE PERITONEAL LAVAGE/BLAKE WBC 14.7 RBC 3.83 HGB 113 HCT 0.34 PLT 260 COSTOPHRENIC SULCI AND HEMIDIAPHRAGMS ARE DIGOXIN
UNDERGONE LAPAROSCOPIC CHOLECYSTECTOMY. A DRAIN INSERTION, SEG 89 LYMPH 5 MONO 6 INTACT.THE OSSEOUS STRUCTURES AND SOFT TISSUE
WEEK AFTER, PATIENT EXPERIENCED HAVING DEBRIDEMENT OF UMBILICAL JUNE 20 ARE UNREMARKABLE.IMPRESSION:- NO ACTIVE LUNG
BLOATEDNESS, BLADDER PROBLEMS, WENT TO THE OR, AREA, 6/21/24 OPERATIVE FINDINGS INFILTRATES.- CARDIOMEGALY- ATHEROSCLEROTIC
WAS GIVEN URIFLOW, PLACED ON CATHETER FOR 2 OMENTAL ADHESIOSN NOTED ON THE AORTA
WEEKS. INTERIM, WITH COMPLAINTS OF HAVING PAIN ON ANTERIOR ABDOMINAL WALL AT THE AREA OF
MOVEMENT. 2 DAYS PTA, PATIENT NOTED PUS DRAINING THE UMBILICIUS, PELVIS, AND LEFT LOWER CT SCAN OF ABDOMEN
FROM THE PERIUMBILICAL AREA, NOTED TO HAVE QUADRANT. LOCALIZED MULTIPE POCKETS OF
CHANGE IN ODOR, COLOR - GREENISH, AMOUNTING TO A ABSCESS, LEFT LOWER QUADRANT AND PELVIC EXAMINATION: CT SCAN OF THE WHOLE ABDOMEN
FULL GLASS, TENDERNESS IN THE UMBILICAL AREA. AREA. DELOCUATION AND DRAINAGE OF (PLAIN) COMPARISON: PRIOR STUDY DATED MAY 23,
PATIENT THEN DECIDED TO SEEK ER CONSULT HENCE ABSCESS CAVITY AND PURULENT MATERIAL 2024. FINDINGS: STOMACH, BOWELS, PELVIS,
THE ADMISSION. APPROXIMATELY 200CC. NOTED SGIMOID AND MESENTERY, PERITONEUM: >MULTIPLE SACCULAR WALL
DENIES HX OF FEVER DESCENDING COLON ADHERENT TO ABSCESS OUTPOUCHINGS ARE AGAIN SEEN IN THE SIGMOID AND
CAVITY. DISTAL DESCENDING COLON. THERE IS ASSOCIATED
ROS: CONFLUENT FAT STRANDINGS AND ADJACENT FASCIAL
(+) EASY FATIGABILITY JUNE 19 THICKENING, WHICH EXTENDS TO THE MIDLINE WHERE
(-) PND COLOR FEW SMALL AIR LOCULES ARE SEEN. CONFLUENT FLUID
(-) PILLOW ORTHOPNEA LIGHT YELLOW, CLOUDY, GLU 3+ BIL NEG KET DENSITIES AND FAT STRANDINGS WITH SMALL AIR
(-) DOB NEG BLOOD NEG PH 6.5 PROTEIN TRACE LOCULES ARE ALSO NOTED IN THE OVERLYING ANTERIOR
(-) PALPITATIONS NITRITE NEG LEUKOCYTES ESTREASE NEG ABDOMINAL WALL AT THE UMBILICUS. >THERE IS A
(-) CHEST PAIN RBC 2.8 WBC 67.3 EPITHELIAL CELLS 3.2 LOBULATED FOCUS OF FLUID AND SOFT TISSUE
ABLE TO CLIMB UP TO A FLIGHT OF STAIR BACTERIA 4505.9 ATTENUATION IN THE PELVIS, PARTLY INSINUATING IN
THE LEFT MESORECTAL REGION. IT MEASURES AT LEAST
PMH: PROTHROMBIN TIME 11.4 6 X 3.2 CM (WXD). >THE STOMACH AND SMALL BOWEL
AF IN CVR, FOR 10-15 YRS %ACTIVITY 100 LOOPS ARE UNREMARKABLE. BOWEL GAS PATTERN IS
INR 1.06 NON-OBSTRUCTIVE. LIVER: NOT ENLARGED WITH
HYPERTENSION, CONTROLLED MEAN NORMAL PT HOMOGENEOUS PARENCHYMA AND NORMAL
UBP 120S ATTENUATION. NO FOCAL MASS LESION. INTRAHEPATIC
HBP140S PTT 32.5 DUCTS AND VESSELS ARE UNREMARKABLE.
PREVIOUSLY ON LOSARTAN AND AMLODIPINE, STOPPED NORMAL CONTROL 31.7 GALLBLADDER: NOT SEEN. PANCREAS, SPLEEN,
ADRENALS: UNREMARKABLE. KIDNEYS: NORMAL IN SIZE
DYSLIPIDEMIA NA 132.0 K 2.8 CREA 76 BUN 4.6 GLU 4.7 AND CONFIGURATION. THE RENAL PELVES AND CALYCES
CHLORIDE 97 IONIZED CALCIUM 1.10 ARE NOT DILATED. THERE IS NO DISCRETE MASS OR
DM, NON INSULIN REQUIRING 30 YRS LITHIASIS NOTED. URETERS: NO DILATATION. NO
WBC 12.9 RBC 4.27 HGB 124 HCT .37 PLT 292 EVIDENCE OF LITHIASIS. URINARY BLADDER:
(-) CAD/CVD/THYROID/KIDNEY SEG 80 LYM 7 MON 12 SUBOPTIMALLY FILLED. NO CALCULUS DEMONSTRATED.
EOS 1 VASCULARITY: NO ANEURYSM. OSSEOUS STRUCTURES:
MAINTENANCE: NO AGGRESSIVE OSSEOUS LESIONS. DEGENERATIVE
DIGOXIN 0.25 MG TAB 1/2 TAB OD SPURS ARE SEEN IN THE SPINE. LYMPH NODES: NO
BISOPROLOL 5MG 1/2 TAB OD ENLARGED RETROPERITONEAL LYMPH NODES. IMAGED
RIVAROXABAN OD CHEST: VISUALIZED LUNG BASES ARE CLEAR.
ATORVASTATIN OD IMPRESSION: COLONIC DIVERTICULITIS WITH POSSIBLE
FEBUXOSTAT OD BEGINNING ABSCESS FORMATION IN THE MIDLINE
GLIMEPIRIDE + METFORMIN OD PERITONEAL AND UMBILICAL REGIONS COMPLICATED
EMPAGLIFLOZIN / LINAGLIPTIN OD FLUID COLLECTION IN THE PELVIS CONTRAST STUDY
SUGGESTED FOR FURTHER EVALUATION
DISCONTINUED:
URIFLOW, LAST WEEK
ASPIRIN

ER VS: 100/70, 88, 20, 37.1, 97%

ALLERGIES:
FOOD: CHICKEN
MEDS: NONE

VACCINE:
(+) COVID VACCINE X BOOSTER
(+) FLU VACCINE
(+) PNEUMOCOCCAL VACCINE

SURGICAL HX:
LAPAROSCOPIC CHOLECYSTECTOMY, MAY 12, 2024

FMHX:
PATERNAL: STROKE
MATERNAL: HYPERTENSION

PSHX:
PREVIOUS CIGARETTE SMOKER, STOPPED 30 YRS AGO,
1PACK A DAY, SMOKED FOR 20 YRS
OCCASIONAL ALCOHOLIC BEVERAGE DRINKER
EXERCISE: LIFTING

▪️S:
SEEN AWAKE, COMFORTABLE, NOT IN APPARENT
CARDIORESPIRATORY DISTRESS
DENIES POST OP SITE PAIN, 2/10 AT THE TIME SEEN
DENIES CHEST/ABDOMINAL PAIN, DIFFICULTY
BREATHING, SHORTNESS OF BREATH
NO HEADACHE, NAUSEA, VOMITING
TOLERATED THE PROCEDURE WELL
NO BOWEL, FLATUS ++

▪️O:
VS:
INTRAOP VS: 100-170/60-100, 80-110, 18-22

HT: 162 CM
WEIGHT: 70KG

ANICTERIC SCLERA, PINK PALPEBRAL CONJUNCTIVAE, NO

PALLOR, NO JAUNDICE
CLEAR BREATH SOUNDS
NORMAL RATE, REGULAR RHYTHM, NO MURMURS
APPRECIATED
SOFT, FLABBY ABDOMEN, (+) INTACT DRESSING OVER
POST OP SITE
PULSES FULL AND EQUAL, NO EDEMA, CRT <2 SECS
NO NOTED NEUROSENSORY AND NEUROMOTOR DEFICITS
904 06/20/2024 ADM INGUINAL HERNIA JUNE 21 P>
UY, JOSEPH GAWANI 70/M 904 CHRONIC ATRIAL FIBRILLATION DIET: DAT, NO PORK AND