FATIMA UNIVERSITY MEDICAL CENTER 120 McArthur Highway, Valenzuela City Department of Surgery Discharge Summary

Name of Patient Age/Sex Date of Admission Date of Discharge Attending Physician Admitting Diagnosis Final Diagnosis Operation

: Quirante, Neil : 40 years /male : 12/20/2011 : 12/22/2011 : Dr. Rivera, Irwin V. : Lacerated wound right knee, hematoma right knee, abrasion right forearm sec to VA : Lacerated wound right knee, hematoma right knee, abrasion right forearm sec to VA : Daily wound care

Chief Complaint: Vehicular accident (self inflicted) History of Present Illness: NOI: VA DOI: 12/20/11 POI: paso de blas service road TOI: 3:00 pm Primary survey: A- Patent B- Spontaneous C- 110/80 D- GCS 15 E- Multiple avulsed wounds at philtrum area, right arm posterolateral area proximal 3 rd and middle 3rd, right hypothenar area,lateral aspect and right knee Secondary survey: A- none M- none P- unremarkable L- 7:30 am F- Few hours prior to consult patient was travelling using his motorcycle, was not able to see an upcoming truck, hence allegedly skid off the road sustaining injuries described. No we, no vomiting, no dizzinesss Past Medical History (-) HTN (-) Diabetes mellitus (-) Cancer (-) Asthma (-) Allergies (-) tb Family Medical History: (+) HPN brother and mother (-) DM (-) Cancer (-) Asthma Personal and Social History: Works as machine operator Non smoker (+) Occasional alcohol drinker Physical Examination: General Survey: Patient is conscious, coherent, wheel chair borne, not in cardiorespiratory distress Vital signs: BP:120/80 mmHg CR:88bpm RR:20 Skin: warm moist with good skin turgor HEENT: Anicteric sclerae. Pink palpebral conjuctive,(-) nasal discharge,(+) dry blood at philtrum area

Temp: 36.9 C

(-) cervicolymphadenopathy Chest and Lungs: Symmetrical chest expansion, no retractions, no lagging, vesicular breath sounds. Heart: Adynamic precordium, Normal rate regular rhythm, no murmur. Abdomen: flabby, normoactive bowel sounds, soft notender Extremities: (+) multiple lacerated wound on right arm and forearm, (+) hematoma right knee Laboratory Examinations:

Hematology 12/20/2011 WBC Differential Count Neutrophil Lymphocyte Monocyte Eosinophil Basophil Hemoglobin Hematocrit 0.72 0.16 0.09 0.01 0.02 130 0.38 13.5 RBC MCV MCH MCHC RDW Platelet MPV PDW 4.42 87 29.4 339 13.2 216 4.45

X RAY of skull APL/T-CAGE/CERVICAL APL/RT. KNEE APL- 12/20/2011 Interpretation HEMOGLUCOTEST 12/20/2011 No radiographic evidence of fracture 158

Course in the Ward: Upon admission. Patient was admitted under the service of Dr. Irwin Rivera. And was placed on Diet as tolerated. Patient was hooked on PLR 1L X 12hrs. Diagnostics requested CBC Xray of skull APL, cervical APL, Tcage, Right knee APL, blood typing and CBG. Therapeutics given CoAmoxiclav 625mg PO q8, Celecoxib 200mg PO BID. Tetanus toxoid and tetanus lgm given. Cold compress on the right knee was placed for 15-20 mins. Vital signs to be monitored every 4hrrs and recorded. On the 2nd hospital day, co amoxiclav shifted to IV 1.2gm q12hr (-) ANST On the last hospital day, cold compress was discounted and warm compress started q4hrs on affected are (right knee). Upon discharge dressing done. IVF consumed. Home medications prescribed.Advised for daily wound care. Disposition: Discharged as improved. Home Medications: Cefuroxime 500mg PO q8hrs x 14days Celebrex 200mg PO q12hrs x 3days Follow-up: Fatima Medical Building on Jan 05,2012 at room 204 at 1:00pm

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Dr.Shakya, S Resident in charge

Jl Gyi, Patricia Surgical Clerk-in-Charge