UNIVERSITY OF SANTO TOMAS HOSPITAL

España Blvd., Manila 1015

Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph

No. 0038622
Medical Abstract
Last Name Birthday Age  Male Admission Date Discharge Date
PASCUAL 09/24/1973 46  Female 02/26/2020 01/17/2020
First Name  Single PhilHealth No. Admission No. Hospital No.
SIMOUN  Married 20B00338 20-160000262644
Middle Name  Widow/er Senior Citizen No. Room/Bed No. Ward
GUINOCOR N/A 212B MEDICINE
Final Diagnosis Primary Diagnosis Patient Contact No.

Secondary Diagnosis

Date of Operation Operation Done

N/A N/A
Surgeon(s) N/A
Anesthesiologists(s) N/A
Attending Physician Dr. Laguesma-Navarro
Condition on Discharge Improved  Not Improved Stable DAMA/HAMA  Expired

Admitting History

Chief Complaint Physical Examination on Admission

Non-healing wounds on both feet General Survey: conscious, coherent, not in cardiorespiratory distress, ambulatory
History of Present Illness Vital signs: BP: 130/80 mmHg, PR: 98 bpm, regular, RR: 20 cpm, Temp: 37.1°C, SpO2: 99%
Skin/Cutaneous: cold, dry skin, (-) pallor, (-) jaundice, (+) multiple erythematous ill-defined
Jan. 2015, patient noted numbness of feet, bilateral, with no other accompanying patches with scaling on the face and scalp
symptoms. No consult was sought, nor medications taken. Head: normocephalic, (-) gross deformities, (-) palpable masses, evenly distributed hair
Eye: pink palpebral conjunctivae, anicteric sclera, isocoric 2-3mm ERTL
Sept. 2019, the wife noticed the patient began to have polydipsia, polyphagia, and Ears: (-) tragal tenderness, (-) aural discharge, intact tympanic membrane AU
polyuria. She also noted weight loss, characterized as arms and legs becoming
Nose: nasal septum midline, non-hyperemic nasal mucosa, turbinates non-congested, no
thinner. Still, no consult sought.
nasal discharge
Nov. 2019, patient was lacerated during machine operations and sustained a 2cm Mouth: pink lips, dry lips and buccal mucosa, (-) oral ulcers, (-) gingival hypertrophy, tonsils
wound. He self-medicated with povidone-iodine, but the wound did not heal. not enlarged and non-hyperemic, (-) exudates, non-hyperemic posterior pharyngeal wall
Instead, the digit blackened over time and became painful and eventually, devoid Neck: trachea in midline, no palpable cervical lymphadenopathies, thyroid not enlarged,
of feeling. neck veins not distended
Respiratory: symmetrical chest expansion, equal vocal and tactile fremiti, resonant on all
Dec. 2019, patient’s right leg was sunburnt, which brought about multiple lung fields, clear breath sounds
erythematous painful blisters on the dorsum of the foot and the anterior lower leg, Cardiovascular: Adynamic precordium, apex beat at 5th LICS MCL, loud S1 followed by a soft
right. These would spontaneously rupture and reveal pink shiny skin. Patient S2 at apex, loud S2 followed by soft S1 at the base, no heaves, no lifts, no thrills, no murmurs
would apply povidone-iodine to the lesions twice a day, yet the lesions persisted. Gastrointestinal: Flat, non-rigid, non-tender abdomen, no visible pulsations, normoactive
No consult done. bowel sounds, tympanitic on all quadrants
Genitourinary: (-) CVA tenderness, (-) suprapubic tenderness
Feb. 1, 2020, patient’s left foot was injured while pushing his motorcycle, which Extremities: (+) gangrenous first digit of the left hand, (+) gangrenous fourth and fifth digits
opened up a heavy bleeding fissure on the lateral side of the fifth toe, left. His left of the left hand, (+) non-healing ulcer on the lower leg, right, (-) pulse on left dorsalis pedis,
foot became swollen, erythematous, and tender. He was brought to Bermudez
all other pulses full and equal
Polymedic Hospital. X-ray showed no osseous changes in both feet but revealed
osteolytic changes in the distal phalanx of the 1st left digit, suggestive of
Osteomyelitis. He was assessed with T2DM and HTN. He was then prescribed Neurological Exam
with unrecalled doses of Cefuroxime (for 7 days), Clindamycin (for 7 days), Conscious, coherent, oriented to time place and person, GCS 15 (E4V5M6)
Prednisone, Linagliptin, Gliclazide, Losartan, Atorvastatin, and B complex. Cranial Nerves:
Amputation of his 5th toe, left, and wound debridement of his right foot were done. CN I – no anosmia
He was subsequently discharged. CN II – intact direct and consensual pupillary light reflex; isocoric pupils 2-3 mm ERTL
CN III, IV, VI – EOMs full intact
Feb. 18, 2020, patient was again admitted at Bermudez Polymedic Hospital due to CN V – can clench teeth; no jaw deviation, no facial sensory deficit
pain on his thumb and feet, characterized as “kumikirot”. He was given CN VII – no facial asymmetry, can smile, frown, raise eyebrows, puff cheeks, close eyes and
Paracetamol/Tramadol 325/37.5 mg/tab PRN, which afforded relief. He was open against resistance
discharged after a few days. CN VIII – gross hearing intact
CN IX, X – uvula in midline
CN XI – can shrug both shoulders with resistance, can turn head side to side against
One day PTC, patient had loss of appetite and felt weakness and dizziness. He resistance
had 5 episodes of yellowish watery diarrhea, amounting to around one glass per CN XII – tongue protrusion in midline, able to do tongue movements
episode. He was brought to USTH ERCD. Incidentally, his HbA1C was elevated at Cerebellum: (-) tremors, (-) dysdiadochokinesia, (-) dysmetria
9.66 and his non-healing wounds were assessed. Patient was toxic-looking and Sensory: 100% on upper extremities, 90% on right foot, no sensation on dorsum of left foot,
weak. He was subsequently admitted.
60% on left sole
Motor: MMT 5/5 on all extremities, except plantar and dorsiflexion
Reflexes: ++ DTR on all, except Achilles tendon reflex
Meningeal: (-) Brudzinski, (-) Kernig’s, (-) Nuchal rigidity

Past Medical History Family History Current Medications:

Adult illness and hospitalization: (+) HTN – father Gliclazide 30 mg/tab BID
(+) HTN (2020) - UBP: 130/80, HBP: (+) DM – mother, maternal Linagliptin 5 mg/tab ODHS
160/90 grandmother Atorvastatin 20 mg/tab ODHS
Previous surgery: None (+) Breast CA – sister Losartan 100 mg/tab OD
Blood transfusion: None (+) stroke – father Clopidogrel 75 mg/tab BID
Allergies: No known allergies (+) CKD – mother Paracetamol/Tramadol 325/37.5 mg/tab PRN

B-complex tablet BID

Admitting Diagnosis
T2DM, poorly controlled; Sepsis sec. to non-healing wound, left thumb, right foot, left foot; ASHD; PAOD; AKI sec. to 1. Dehydration, 2. Sepsis
Prepared By: Designation Date

PEREZ DE TAGLE/PONCE/QUENERI/RABARA/RAGPA CLINICAL CLERKS-IN-CHARGE 02/21/2020

SIGNATURE OVER PRINTED NAME
080115-MD-F04 rev 4

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 UNIVERSITY OF SANTO TOMAS HOSPITAL
España Blvd., Manila 1015
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph

Clinical Discharge Summary

Problems Action/Intervention
Upon admission (02/26/2020), patient was awake, not in distress, and afebrile. Patient was asymptomatic, with good oral intake, good urine output, and
generally asymptomatic. On admission, patient had elevated creatinine at 6.44 mg/dL and elevated iPO 4 at 6.08 mg/dL, along with low Na at 132.00
mmol/L and K at 3.19 mmol/L. Upon insertion of the heplock, the patient was started on PNSS with 40 mEq KCl that was run on 40 cc/hr. KUBP was
requested and a repeat Na/K was done 8 hours after IVF was started which revealed a Na of 131.00 mmol/L and K of 3.04 mmol/L.

On the first hospital stay (02/27/2020), patient was awake, not in distress, had no recurrence of dizziness, no dyspnea, no chest pain, but with pain over
the left hand and both legs. Patient had 1 episode of fever wherein Paracetamol 500mg/tab was given. Vital signs were BP 110-140/70-90, RR 19, Temp
36.5-38, PR 98-109. Patient had normal sodium and potassium levels. CBG was monitored, lowest value was 67 and highest value was 150. Initial 2D
echo with Doppler studies was done which showed concentric LV remodeling NRSF and IR NRVSF, AR mild, TR mild, AA, Normal PAP, Incidental finding
of pleural effusion. EF: 72%.

On the second hospital stay (02/28/2020), patient was awake, comfortable, not in distress, no febrile episodes and denies chest pain. No episode of loos
bowel movement. CBG was monitored TIDACS, lowest is 113 mg/dl and highest is 136 mg/dl. KUBP was done and showed normal-sized kidneys with
diffuse parenchymal changes, bilateral, with a septated cortical cyst, right.Normal sonogram of the urinary bladder and prostate. AV duplex scan revealed
Lower extremity arterial disease, Atherosclerotic. Right: HSS (>50%) of the distal femoral artery and dorsalis pedis artery.Left: HSS (>50%) of along the
dorsalis pedis artery .No evidence of acute DVT both lower extremities. Still for OR

Physical Exam on Discharge

Physical Examination on Admission Neurological Exam
General Survey: Ambulatory, conscious, coherent GCS 15 Cranial Nerves:
Vital signs: BP: 90/60 mmHg PR: 118 bpm, regular RR: 19 cpm , CN I – not assessed
regular Temp: 36.9°C SpO2: 98% at room air CN II – anisocoric pupils 2-3mm ERTL
2
Anthropometrics: Weight: 44.8 kg, Height: 161cm, BMI 17.29 kg/m CN III, IV, VI – EOMs full and equal
Skin/Cutaneous: (+) pallor, (-) jaundice, (-) cyanosis, (-) hematoma, CN V – can clench teeth, (-) sensory deficit
(-) petechiae CN VII – Can smile, puff cheeks, raise eyebrows, close eyelids against full
Eye: pale palpebral conjunctivae, anicteric sclera, isocoric 2-3mm resistance
ERTL CN VIII – (-) Lateralization; AC > BC, AU
Ears: (-) tragal tenderness, (-) aural discharge, non-hyperemic EAC CN IX, X – uvula midline
Nose: (-) nasal discharge, septum midline, nasal turbinate not CN XI – can shrug shoulders with resistance, cannot turn head side to side
discharged CN XII – tongue deviated to the right, able to do tongue movements
Mouth: Moist buccal mucosa, (-) lesions, tonsils not enlarged, non- Cerebellum: (-) ataxia, (-) dysmetria, (-) dysdiadochokinesia
hyperemic posterior pharyngeal wall Motor: 5/5 MMT on all extremities
Neck: Thyroid midline and moves with deglutition, (-) thyroid Sensory: No sensory deficit on all extremities
enlarged, (+) cervical and supraclavicular lymphadenopathy, trachea Reflexes: ++ DTR on all extremities
midline, (-) neck veins distention,
Respiratory/chest: (+) necrotic breast mass measuring 12 x 7 cm Meningeal: (-) Brudzinski, (-) Kernig’s, (-) Nuchal rigidity
extending on the axillary area, left and (+) cystic mass on right
breast, symmetrical chest expansion, (-) retractions, normal breath
sounds, equal tactile and vocal fremitus
Cardiovascular: Adynamic precordium, apex beat at 5th LICS MCL,
no heaves, no lifts, no thrills, no murmurs
Gastrointestinal: soft, flabby abdomen, normoactive bowel sounds,
tympanitic on all quadrants, nontender
Genitourinary: (-) CVA tenderness
Extremities: pulses full and equal, CRT <2sec, (+) edema on left
arm
Imaging Pertinent Laboratory Results Operative Findings

See attached LFS See attached LFS N/A

Histopathologic Diagnosis

N/A

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 UNIVERSITY OF SANTO TOMAS HOSPITAL
España Blvd., Manila 1015
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph

Follow-Up Record
Last Name PASCUAL BIRTHDATE AGE GENDER
09/24/1973 46  Male
PATIENT NAME First Name SIMOUN  Female

Middle Name GUINOCOR

Ward Room/Bed No. Admission No. Hospital No. Admission Date Discharge Date
Medicine 212B 20B00338 20-160000262644 02/26/2020
Final Diagnosis Primary Diagnosis

Secondary Diagnosis

Date of Operation Operation Done Anesthesia Technique Rendered

N/A N/A N/A
Patient’s Condition at  Improved  Not Improved  Stable  DAMA/HAMA  Expired
Time of Discharge Vital Signs State Reason For DAMA/HAMA Primary Cause of Death
BP N/A N/A
Mark X on The Box HR
RR
Temp
Pain Score
Any Important Precautions: (Wound Care/Diet/What to Avoid/Activities Allowed for Patient)

Please seek medical care if the following SIGNS/SYMPTOMS are present:

If Urgent Care Is Needed

FOLLOW-UP ON DATE: ___01/30/2020__ ____ CALL THIS
(MM/DD/YYYY) TELEPHONE
NO.:

CALL THIS
PERSON:

WHERE TO GO FOR FOLLOW-UP: MARK WITH X

 OPD – Anesthesia
 OPD – Dermatology
 OPD – ENT
 OPD – Fam Med
 OPD – Medicine NAME PEREZ DE TAGLE/PONCE/QUENERI/RABARA/RAGPA
 OPD – Neurology SIGNATURE OVER PRINTED NAME
 OPD – OB-GYN
 OPD – Ophthalmology
 OPD – Pediatrics
 OPD – Rehab Med
 OPD – Surgery
 USTH Doctor’s Clinic: Room No. _____
DESIGNATION CLINICAL CLERKS-IN-CHARGE

DISCHARGE DOCUMENTS to be completed CERTIFIED CORRECT BY:

NAME
 Discharge Medication Sheet  Hospital PSS DR. LAY/DR. BADION
 Follow-up Record  Discharge slip SIGNATURE OVER PRINTED NAME

DESIGNATION RESIDENTS-IN-CHARGE

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 UNIVERSITY OF SANTO TOMAS HOSPITAL
España Blvd., Manila 1015
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph

DISCHARGE MEDICATION SHEET

Last Name PASCUAL BIRTHDATE GENDER Admission Date
Patient 09/24/1973  Male 02/26/2020
Name First Name SIMOUN Age  Female Discharge Date
46 01/17/2020
Middle Name GUINOCOR Discharge Diagnosis

MEDICATIONS
Brand (Generic) Name Dose Frequency Duration/End of Intake
(Pangalanng Gamot) (Dosis) (Dalas ng Pag-Inom) (Bilang ng araw at huling petsang pag-inom ng gamot)

Special Instructions/Alerts:

Accomplished By: Approved By:

PEREZ DE TAGLE/PONCE/QUENERI/RABARA/RAGPA DR. LAY/DR. BADION

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
Designation: License No.: PTR No.:
CLINICAL CLERKS-IN-CHARGE

DISCHARGE INSTRUCTION ACKNOWLEDGE

BY: __________________________________________________________________________________
PATIENT/PATIENT REPRESENTATIVE (SIGNATURE OVER PRINTED NAME)

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