referral roman by dredwardmark


									INTERDEPARTMENTAL REFERRAL FORM Department of Internal Medicine

NAME: Roman, Remedios Address: 1334 Albina St. Sta. Mesa, Manila DEPARTMENT/WARD/ROOM NO. IM - 427 Present Working Impression: Drug – Induced Hepatitis Acid Peptic Disease Pleural Effusion, right probably secondary to: 1. PTB 2. Parapneumonic Process Cholecystolithiasis Physicians-in-Charge: Drs. Dalanon/Gutierrez/Gregorio Date/Time Referred: July 3, 2007 Referred to: Surgery Department Date/Time Received:

Hospital No. 1446764 Age/Sex: 46/F

Reason for Referral: for evaluation of Chelecystolithiasis

For: __x__ Co management _____ Opinion and suggestion only _____ Pre-operative Evaluation _____ Transfer of Service _____ Others

STAT _______ Routine__x___

Opinion and Suggestion:

________________________ Referring Physician

________________________ Receiving Physician

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