chavez PDS

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NAME: CHAVEZ, AUREA SANDOVAL AGE/SEX: 55/F ADDRESS: Kenro st., Airport view, Paranaque City DATE ADMITTED: Aug 1, 2008 ASSESSMENT: SCCA, Mandible, Left PHYSICIANS IN CHARGE: Drs. Samson/So/Del Valle/Ricardo/Catignas/Regino CLERKS IN CHARGE: Fabian/Ilarde/Ingles/Item/Junsay

HOSPITAL NO.: 1502008

PATIENT DISCHARGE SUMMARY History of the Present Illness 3 months PTA, patient noted an ulceration on her mandible, left which progress as days goes by, with associated pain and foul smell, no associated history of ingested foreign body, no use of “nga-nga”. Patient consulted PGH, biopsy done and was ordered operation but was advised to wait for a long line before her time of operation. Patient consulted our institution for further evaluation and management hence this admission. Past Medical History No previous operation No asthma No Allergies Family History (+) Cancer, Oral Cavity (Uncle) Review of Systems (+) wt loss, (-) anorexia (-) fever (-) eye pain, (-) tinnitus, (-) epistaxis, (-) hoarseness, (-) difficulty swallowing (-) cough, (-) colds, (-) hemoptypsis, (-) chest pain (-) abdominal pain, (-) constipation, (-) changes in bowel habits (-) dysuria, (-) hematuria (-) seizures, (-) convulsions (-) edema PHYSICAL EXAMINATION General Survey Conscious, coherent, NICRD Vital Signs BP = 130/70 HR = 76 RR = 19 Temp = 37.0 EYES: pink palpebral conjunctivae, anicteric sclera, PERTL 2-3 mm CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds HEART: adynamic precordium, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, non-tender EXTREMITIES: grossly normal, full and equal pulses, no cyanosis, no edema ENT Exam

intact tympanic membrane

(-) tragal tenderness

(-) septal deviation (-) congestion

(+) mandibular mass, 10x10cm Non-movable, tender

(+) fungating mass w/ ulceration (+) foul smelling

ASSESSMENT: PLAN: for admission The patient was admitted to room 214 under the service of Drs. Samson/So/Del Valle/Ricardo/Catignas/Regino. Consent for this admission was obtained from the patient. TPR every shift and recorded. Patient can take diet as tolerated. Diagnositc Exams ordered were Urinalysis, CBC, CT BT, CXR PA, Mandible APO and Blood typing. Patient is for elective Selective Commando w/ Tracheostomy (pectoralis major reconstruction) under G.A. 6 units of whole blood properly typed and cross-matched were to be secured. VSq4. Patient’s weight was 38 kg. Internal Medicine Department was informed regarding this admission. On the 1 hospital day, patient may have DAT, for TPAG and rpt CT, BT. Follow-up blood typing results. Patient is for elective Commando with tracheostomy on Tuesday. Dr filio is to be informed regarding this admission. Patient is continued with antihypertensive meds. VSq4. On the 2 hospital day, patient may have DAT, for TPAG and rpt CT, BT. Follow-up blood typing results. Patient is for elective Commando with tracheostomy on Tuesday. Dr filio is to be informed regarding this admission. Patient is continued with antihypertensive meds. VSq4. On the 3 hospital day, patient was for PT, PTT, was hooked to D5LR 1L x 5 hours now then give vit K as advised. Patient was given Cefurtoxime 1-5gm TIV ANST, then next dose was given intraoperative. TPAG result was for follow-up. Vital signs monitored every 4 hours. In the afternoon, PT & PTT result was in and refered back to Anesthsiology. Patient had pre-meds at OR order and may go ahead with contemplated procedure. On the 4 hospital day, patient was brought to the OR and contemplated procedure was done. Patient was then brought to PACU and was S/P Commando/GETA. Vital signs was monitored every 15 minutes. O2 suport was given and was under NPO. IVF: PNSS 1L x KVO (for BT), D5LR 1 L x 8 hours. Medications: Diclofenac 75mg TIM q8. Tramadol 50 mg TIV q6 x 4 doses, Ranitidine 50mg TIV q8 x 4 doses. Patient was kept thermoregulated. Patient was placed moderate- high back rest. Patient’s I & O was monitored q1. Patient was transfused with 1 u PRBC to run for 2 hours. Post BT H & H was done after 6 hours. O2 support was given thru Tpiece. Post-op xray and 12 L ECG was done. Secretions suction PRN. Patient was given furosemide 20mg TIV slowly after having a urine output of 56cc for 3 hours. Patient was also given 200cc of PLR Fast drip. On the 5 hospital day, patient was awake with stable vital signs and fully recovered from the immediate effect of anesthetic. Patient was transferred to ward. Patient was continued with present management. Vital signs, input and output was monitored every hour. Daily wound and traceostomy care done. Start nebulization with combivent q6 alternating with 2ml of PNSS. In the afternoon, patient’s O2 support was continued, maintained on NPO, IVF continued, tramadol drip discontinued, CBC with PC done, Ranitidine continued while on NPO, Nubain drip was started, nebulization as well as vital signs monitoring and urine output monitoring was continued. On the 6 hospital day, BUN, crea, Na, K, ABG’s, ECG was done, CXR- AP was deferred at the moment, paracetamol orders was done, 1 unit PRBC was transfused, vital signs monitored q15 while on BT. IVF was shifted to PNSS 1L x 125cc/hr, previous orders was carried out, CXR AP was carried out and referred. Nicardipine drip was started due to high BP (160/90) at 90 cc D5w + 10mg nicardipine in soluset to run at 10ugtts/min. Cefuroxime was started 1 vial q8 TIV. Input, output and vital signs were monitored q1. Patient was transferred to Infirmary room 319. On the 7 hospital day, referral to IM service was followed-up. Patient was done with TSB, IVF/ IV meds. VSq1 I & O q1. Paracetamol was given. Tracheostomy care done, secretions were sunctioned. O2 support was given. Patient was awake, conscious, (+) pain on surgery site, BP140/80, CR92, RR22, T37.5, Input 3810, output 1612, UO 67.17 cc/hr, Nicardipine drip was continued as well as tramadol drip. Repeat CBC was done and referred back to IM. In the afternoon, nicardipine drip was discontinued. On the 8 hospital, patient was refered back to IM due to high BP and had an assessment of HCVD, LVH, ST, NIF. Nicardipine drip was resumed to run at 10 ugtts/ min. Patient was continued on NPO, O2 support was continued, medications were continued, nebulization was continued, wound care done, secretions suctioned, VSq1, I&Oq1 and recorded. In the afternoon nicardipine drip was increased to 15 ugtts/minute and MAP maintained at 95mmhg. CBG monitoring done every 6 hours. On the 9 hospital day, patient was referred back and seen by service consultant, maintained on moderate to high back rest, started on milk formula ENSURE 30cc q1 via ngt, H20 as needed, started with OF/NGT 2000 kcal/L in 6 divided feeding, discontinued tramadol drip, shifted to celecoxib 200mg via NGT q12 and Diclofenac Na 75mg via NGT PRN for pain, started on ranitidine 150mg/tab
th th th th th th rd nd st

vai NGT q12, started on oral hygiene with H202/ oral and H20 qid then betadine gargle, foley catheter was removed, TPAG CBC and UA done, VS q1, inspect and output q1 and recorded.

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