HAND OFF COMMUNICATION FORM

9B
NOVEMBER 2, 2024
917 CHATA, CORAZON 75/F ADM DIAPHRAGMATIC HERNIA OCT 30 OCT 31 10/27 PIPERACILLIN TAZOBACTAM 4.5G IV Q8 – D5 – PENDING
ADM: 10/27/24 PAU DIVERTICULOSIS K 3.7 WAB CT FOR INTRAABDOMINAL INFECTION SPUTUM GSCS – NO SPECIMEN YET
705 ICU: 10/30 VISTAL (PER CAP MR (?) IMPRESSION: POST-OPERATIVE CHANGES AT THE LOWER CONTEMPLATING DISCHARGE
TELE 705 10/31 REQUEST) HYPERTENSION OCT 28 INTRATHORACIC REGION AS DESCRIBED CONSIDER SPLENIC TRAMADOL 50MG IV Q8 PRN
MS5 MREYES (T/C FBS 5.0 BUN 5.5 CREA 82.4 URIC 288.6 AST 21.6 ALT 21.6 ALP INFARCTION GALLBLADDER HYDROPS WITH LITHIASES RENAL OMEPRAZOLE 40MG IV OD DIET: GEN LIQS >> PROGRESSING DIET
MAIN AP: DR. VISTAL LANTONIO) S/P DIAGNOSTIC LAPAROSCOPY, LAPAROSCOPIC 124 NA 140 K 2.8 CL 105 CA 2.15 ALB 39.3 CHOLE 4.79 TG CORTICAL CYSTS, RIGHT COLONIC DIVERTICULOSIS WITHOUT SIGNS PARACETAMOL 600MG IV Q6 PRN IVF: B FLUIDS X 16 HOURS
1020 OTHER AMDS: DR ANTONIO, DR SABLAN, DR SARMIENTO (SURGERY) MTR (T/C SABLAN) REPEAIR OF HIATAL HERNA (10/30/24) 0.98 HDL 1.65 LDL 3.4 VLDL 0.45 OF INFLAMMATION ATHEROSCLEROSIS CLONIDINE 75MCG PRN O2: RA. NO DESATS. NO COUGHING
CBG: Q4 WHILE ON NPO
CC: ABDOMINAL PAIN RSARMIENTO OCT 27 BRAIN CT
NEURO URINALYSIS IMPRESSION: MICROVASCULAR ISCHEMIC CHANGES AND CHRONIC EVENTS:
HPI: PSYCH LY SL CLOUDY GLUC (-) BILI (-) KETONE (-) SG 1.020 BLOOD LACUNAR INFARCTS MILD CEREBRO-CEREBELLAR VOLUME LOSS 10/30 S/P DIAGNOSTIC LAP
2 WEEKS PRIOR TO ADMISSION, PATIENT EXPERIENCED PRODUCTIVE TRACE PROTEIN 1 + UROBILI NORMAL NITRITE (-) LE (-) RBC ATHEROSCLEROSIS SPHENOID SINUS DISEASE TRANSFERRED TO ICU FOR CLOSER
COUGH WITH ASSOCIATED COLDS. TOOK TUSERAN FORTE FOR 2 WEEKS 17.3 WBC 7.4 EC 30.5 BACTERIA 146.2 HYALINE CAST 25-30 CONSIDERED NEURO REF MONITORING
BUT WITH NO RELIEF OF SYMPTOMS. HGB 128 HCT 0.40 WBC 4.8 SEG 78 LYMPH 12 PLT 279
OCT 29 REF TO MTR AND MREYES FOR
2 DAYS PRIOR TO ADMISSION, PATIENT HAD GENERALIZED ABDOMINAL RAT (-) 2DED EF 69% CLEARANCE
PAIN PS 10/10 WITH ASSOCIATED NAUSEA AND UNDOCUMENTED PT 10.4 VS 10.6 %ACT 99 INR 0.98 COLOR FLOW AND DOPPLER STUDY: HAD ELEVATED BPS BUT NICARDIPINE
FEVER. NO CONSULT/MEDS DONE PTT 34.3 VS 32.6 MILD MITRAL. TRICUSPID AND PULMONIC REGURGITATION CLAMPED
LIPASE 5 GRADE 1 LV DIASTOLIC DYSFUNCTION
1 DAY PRIOR TO ADMISSION, PERSISTENCE OF ABDOMINAL PAIN NA 138 K 3.0 CREA 65 BUN 4.0 GLUC 8.6 CL 101 IVA 1.13 NORMAL ESTIMATED PULMONARY ARTERY SYSTOLIC PRESSURE OF 10/31
PROMPTED CONSULT AT THE ER. HGB 122 HCT 0.37 WBC 5.5 SEG 86 LYMPH 7 PLT 293 25 MMHG BY TR JET CRANIAL AND WAB UTZ PRIOR TO
CONCLUSION: TRANSFER:
CT SCAN WAS DONE WHICH SHOWED DIAPHRAGMATIC HERNIA. NORMAL LEFT VENTRICULAR SIZE AND GEOMETRY WITH NORMAL - RENAL CYST, SPLENIC INFARCT
PATIENT WAS GIVEN PAIN MEDICATIONS. ADVISED FOR PROCEDURE SYSTOLIC FUNCTION. MILD DIASTOLIC DYSFUNCTION - DIVERTICULOSIS WITHOUT
BUT OPTED FOR DAMA. MILD DILATED LEFT ATRIUM, MILDLY ELEVATED LEFT ATRIAL EVIDENCE OF INFLAMMATION
VOLUME INDEX (LAVI), NO APPARENT THROMBUS - POST OP CHANGES, GALLBLADDER
DOC, PATIENT EXPERIENCED NAPE PAIN AND TOOK LOSARTAN WHICH NORMAL RIGHT VENTRICULAR SIZE AND SYSTOLIC FUNCTION. HYDROPS – EXPECTED FINDINGS
OFFERED RELIEF TO THE SYMPTOMS. NOTED PERSISTENCE OF NORMAL SIZED RIGHT ATRIUM. MITRAL AND AORTIC VALVE - MICROVASCULAR ISCHEMIC
ABDOMINAL PAIN HENCE WENT BACK TO THE ER FOR THE PROCEDURE SCLEROSIS, MILD MITRAL AND AORTIC REGURGIITATION. MILD CHANGES – SURGERY SERVICED
HENCE ADMITTED. TRUSCPID AND PULMONIC REGURGITATION. NORMAL ESTIMATED ASSESSED
AND PULMONARY ARTERY SYSTOLIC PRESSURE
UNREMARKABLE AT THE ER THICKENED AORTIC WALLS. WITH BOUTS OF INTERMITTENT
ABDOMINAL PAIN
ROS CHEST X-RAY TRAMADOL DRIP BUT HAD NAUSEA –
(-) BM X 3 DAYS COMPARISON: OCTOBER 26, 2024 > DISCONTINUED
LOSS OF APPETITE HAZY OPACITIES REMAIN PRESENT IN THE RIGHT PARACARDIAC
REGION; SIMILAR OPACITIES ARE NOW SEEN IN THE LEFT LUNG UNREMARKABLE WARDS
PMHX: BASE; PNEUMONIA AND / OR ATELECTASIS ARE CONSIDERED.THE TRANSFERRED TO ICU POST OP
(+) HYPERTENSION PREVIOUSLY REPORTED SOFT TISSUE FULLNESS AT THE LOWER ELEVATED BP, NICARD
(+) HIATAL HERNIA X 5 YEARS MEDIASTINAL REGION, OVERLYING THE CARDIAC SHADOW, IS LESS THEN TELE – OFFF NICARD POST ICU
(+) DIVERTICULOSIS EVIDENT ON THIS EXAMINATION. CT-SCAN CORRELATION MAY BE
(-) ASTHMA DONE IF CLINICALLY WARRANTED.THE HEART IS ENLARGED. THE 11/1 ABDOMINAL PAIN (FEELING
(-) PTB AORTA IS CALCIFIED.THE LEFT SULCUS IS NOW OBSCURED; THE BUMUKBUKA YUNG HIWA)
ALLERGIES: NONE PRESENCE OF PLEURAL EFFUSION IS POSSIBLE. HYPERTROPHIC NO COUGH
PREVIOUS SURGERIES: DEGENERATIVE CHANGES ARE SEEN IN THE VISUALIZED OSSEOUS TRANSFER PER REQUEST
S/P HYSTERECTOMY STRUCTURE.
PREVIOUS HOSPITALIZATIONS:
S/P COLONOSCOPY AUG 2024 (DIVERTICULOSIS, HEMORRHOIDS) OCT 26
WHOLE ABDOMEN CT SCAN
MAINTENANCE MEDICATIONS: PROGRESSION OF THE DIAPHRAGMATIC HERNIA WITH
LOSARTAN 100MG OD INTRATHORACIC
ATENOLOL 50MG OD DISPLACEMENT OF MOST OF THE STOMACH (DISPLACED TO THE
AMLODIPINE 10MG OD RIGHT) AND NOW THE TRANSVERSE COLON
CHOLELITHIASES WITHOUT CT SIGNS OF CHOLECYSTITIS
FMHX: RENAL CORTICAL CYSTS, RIGHT
(+) HYPERTENSION- PATERNAL COLONIC DIVERTICULOSIS WITHOUT SIGNS OF INFLAMMATION
(-) TYPE 2 DM NON-DELINEATED UTERUS
(-) CANCER ATHEROSCLEROSIS
DEGENERATIVE OSSEOUS CHANGES AND DISC DISEASE
PSHX: ANTEROLISTHESIS, L4 OVER L5 (GRADE I) AND L5-S1 (GRADE II)
NON SMOKER INCIDENTAL FINDINGS, AS DESCRIBED
NON ALCOHOLIC BEVERAGE DRINKER
CXR
OBHX: CONSIDER PNEUMONIA. PLEASE CORRELATE CLINICALLY.
G5P3 CARDIOMEGALY.
ATHEROSCLEROTIC AORTA.
AT THE ER, SOFT TISSUE FULLNESS IN THE LOWER MEDIASTINAL REGION. CT
108/75, 101, 20, 37.7, 95% CORRELATION SUGGESTED.
DEGENERATIVE SPINE CHANGES AND OSTEOPENIA.
CURRENTLY,
SEEN AWAKE, COMFORTABLE
NO COMPLAINTS OF CHEST PAIN, DYSPNEA, PALPITATIONS
(-) ABDOMINAL PAIN
(-) NAUSEA
(-) NAPE PAIN

HT: 160 CM WT: 59 KG

NO PALLOR, NO JAUNDICE
ANICTERIC SCLERAE, PINK PALPEBRAL CONJUNCTIVAE
CLEAR BREATH SOUNDS
NORMAL RATE AND REGULAR RHYTHM
FLABBY, NON DISTENDED, NORMOACTIVE BOWEL SOUNDS, NON
TENDET
FULL AND EQUAL PULSES
NO BIPEDAL EDEMA
918 *PATIENT:* PILAZA, EPIFANIA 89/F CPCL DISLOCATED ANTEROINFERIOR RIGHT HUMERAL NOV 2 NOV 2 *REVIEW OF MEDICATIONS* P:
*ROOM:* 918 HEAD NA 130 K 3.6 CREA 95 BUN 5.1 GLUC 7.7 CL 96 ICA 1.12 CXR TRAMADOL 50 MG IV Q8 IVF: D5LR 1L X 8 HOURS
REF 11/2 AAGONCILLO HYPERTENSION IMPRESSION:CONSIDER KOCH'S ETIOLOGY IN THE LEFT APICAL DIET: NPO
WBC 8.6 RBC 3.96 HGB 142 HCT 0.41 PLT 202 SEG 83 REGIONRULE OUT MINIMAL LEFT PLEURAL O2: ROOM AIR
*▫️HISTORY:* EFFUSIONCARDIOMEGALYATHEROSCLEROTIC AORTA
NOI: FALL *PENDING:*
TOI: 19:00H XRY: HAND UNILATERAL 3 VIEWS 11/2: 2DED
DOI: NOV 1 IMPRESSION:UNREMARKABLE STUDY
POI: HOME AT MUNTINLUPA 🔳 *PLANS*
XRY: RIGHT SHOULDER 🔘 INITIAL RCRI: 1 POINT, CLASS II RISK
PATIENT SUSTAINED A RIGHT SHOULDER DISLOCATION ALLEGEDLY THERE IS ANTERO-INFERIOR DISLOCATION OF THE RIGHT HUMERAL - PATIENT IS STRATIFIED AS
AFTER TRIPPING AND BUMPING ON A COFFEE TABLE AND THEN FELL TO HEAD.SOFT TISSUE SWELLING IS NOTED IN THE SHOULDER INTERMEDIATE RISK TO DEVELOP
HER RIGHT SIDE REGION.THE REST OF THE OSSEOUS STRUCTURES AND SOFT TISSUES ADVERSE CARDIAC EVENTS IN A LOW
ARE UNREMARKABLE RISK PROCEDURE
*PAST MEDICAL HISTORY:*
(+) HYPERTENSION XRY: RIGHT HUMERUS AP/LAT *PROCEDURE:* CLOSED REDUCTION
- AMLODIPINE 2.5 MG TAB OD IMPRESSION:UNREMARKABLE STUDY OF RIGHT SHOULDER
*SCHEDULE:* NOV 2, 2024
*SURGICAL HISTORY:* XRY: RIGHT ELBOW AP/LAT (SATURDAY), 11:00H
S/P OPEN CHOLECYSTECTOMY NO DEFINITE FRACTURES OR DISLOCATION NOTED.SOFT TISSUE
S/P OPEN APPENDECTOMY SWELLING IS NOTED IN THE ELBOW REGION.THE OSSEOUS