DAILY CENSUS

JULY 4-5, 2017

 OBSTETRICS

Admissions 1

NSD 1

CS 0

GYNECOLOGY

Co-management 3

Direct to Room 0

ER Admission 0

Consult 0
 Consultant On Call:
Dr. Cora Quijano

Residents on Duty:
Dr. Jed Balcita
Dr. Patricia Tan
Dr. Eloisa Glovasa
Dr. Maria Lourdes Carabaña
Dr. Nina Yang
Dr. Corina Lumapas

Senior Clerks on Duty

Lomocso, Roldan, Yongphumphuttha
Admission 1
Name Age Parity Chief Admitting Plan/Final Diagnosis
Complaint Diagnosis
AC 25/F Gravida 1 Labor Pregnancy Gravida 1 Para 1 (1001)
Para 1 pains Uterine 38 2/7 Pregnancy Uterine
(1001) weeks AOG Delivered via
spontaneously a Live Term
Baby Boy in Cephalic
Presentation with APGAR
score 8,9 Ballard score 39
weeks Birthweight 2,650 g
Appropriate for
Gestational Age
Laboratory Results

Complete Blood Count taken 7/4/2017 at 10:20 pm

Blood Count Result

White Blood Cells 12.81
Red Blood Cells 4.02
Hemoglobin 11.3
Hematocrit 33.7
Platelet 356
Laboratory Results

Urinalysis taken 7/4/2017 at 10:39 pm

Physical Characteristics Result

Color Yellow
Transparency Clear
pH 7.0
Specific Gravity 1.015

Other findings in the urinalysis are unremarkable.

Admitting CTG
 Full Dilatation= 12:17am
10 -3

9 Baby Out= 12:17am

-2
Placenta Out = 12:32am
8

7 -1 S
T
A
T
6 I
0 O
N
5

4 +1

3
+2
2

1
+3

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
16
TIME (hours)
GYNECOLOGY
 ER Resident on Duty:
Dr. Glovasa

Ward Resident on Duty:

Dr. Carabana

PGIs on duty
Dr. Yap, Quijano

Senior Clerks on Duty

Alvizo, Patriarca
 Co-Management 1
Name Age/ Chief Admitting Diagnosis Plan/ Final Diagnosis
Status Complaint
S, M.J. 35/M Vaginal Abnormal Uterine - Scheduled for
Spotting Bleeding secondary Dilatation and
to Endometrial Curettage at 7am
Pathology
-Medications:
Cefoxitin 2gm IV
infusion vial ANST then
every 6 hours,
Sulbactam-Ampicillin
1.5g IV 1 hour prior to
OR, Omeprazole
40mg IV 1 hour prior
to OR, Ranitidine HCL
50mg IVTT tomorrow
at 6am,
Dexamethasone 5mg
IVTT tomorrow at 6am
 CBC 07/10/17
CBC 07/10/2017 6:53 PM
6:53 PM Differential Count
Blood Count NEUTROPHIL 54.4
WBC 10.12 LYMPHOCYTE 37.1
RBC 3.98 MONOCYTE 5.0
Hemoglobin 12.1 EOSINOPHIL 3.1
Hematocrit 35.6 BASOPHIL 0.4
Platelet 275
Blood Indices
PROTHROMBIN TIME 07/10/17
MCV 89.4 6:53 PM
MCH 30.4 Patient 12.7
MCHC 34.0 Activity 109
RDW 13.8 INR 0.95
PDW 9.5 Control 13.3
MPV 9.5 Control Activity 100
PREGNANCY TEST: NEGATIVE; SERUM CREATININE: 0.8 mg/dL (normal)

TRANSVAGINAL UTZ
FINDINGS OF CONCERN:
I. Uterus 9.0x7.1x6.5cm; Anteverted with smooth contour and homogenous
echopattern. No uterine masses seen.
II. Endometrium 4.29 cm; Irregularly thickened and heterogenous with intact
subendometrial halo. Minimal color flow is demonstrated on color
flow mapping of the thickened endometrium.
III. Adnexae Right ovary 2.4x3.0x2.0cm lateral to uterus. It contains small
follicles and appears unremarkable. Left ovary 2.2x3.0x1.9cm
lateral to uterus. Within the left ovary is a single cystic follicle
measuring 1.2x1.3x1.0cm. No adnexal masses seen.
IV. Cervix 3.6x3.0x3.1cm, homogenous, Nabothian cyst present
V. Cul-de-sac Scanty clear fluid

IMPRESSION
Normal-sized anteverted uterus with intact irregularly thickened heterogenous
endometrium, as described, suspicious of an endometrial pathology. Unremarkable
right ovary. Single cystic follicle, left ovary. Scanty, clear, cul-de-sac fluid.
 Co-Management 2
Name Age/ Chief Clinical Impression Plan/ Final Diagnosis
Status Complaint
M, M. 26/S Hypogastric Pelvic Inflammatory - Labs: TVS
pain Disease o Pap smear with
gram staining for
cervicovaginal
discharges, TVS
- Medications:
o Clindamycin
Phosphate 900mg
IV ANST every 8
hours, Gentamycin
Sulfate 240mg IV
ANST once a day,
Cefuroxime
Loading Dose: 1.5g
IVTT ANST,
Maintenance Dose:
750mg IV every 8
hours
 CBC 07/10/17
CBC 07/10/2017 6:53 PM
6:53 PM Differential Count
Blood Count NEUTROPHIL 58.7
WBC 7.8 LYMPHOCYTE 32.6
RBC 4.83 MONOCYTE 6.9
Hemoglobin 12.9 EOSINOPHIL 1.3
Hematocrit 40.3 BASOPHIL 0.5
Platelet 327
Blood Indices
CLINICAL CHEMISTRY 07/10/17
MCV 83.4
7:55 PM
MCH 26.7 CREATININE 0.6
MCHC 32.0 SGPT-ALT 26
RDW 13.6 SODIUM 131
PDW 9.5 POTASSIUM 3.8
MPV 9.1
URINALYSIS 07/10/2017
7:31 PM
Physical Characteristics

Color Light Yellow

Transparency Clear
pH 6
Specific Gravity 1.010
Chemical Characteristics

Blood 15
Microscopic Findings

Within normal limits

PREGNANCY TEST: NEGATIVE,

SPECIFIC GRAVITY 1.010
(TAKEN AT 6:53 PM, July 10)
WHOLE ABDOMEN UTZ
FINDINGS OF CONCERN:
Few tiny, low density calculi are seen in both kidneys. No definite pelvo-calyceal
fullness is seen. The left ovary is physiologic in appearance. The right ovary is not
delineated, however, there is a slightly thick walled cystic area seen in right
adnexal region measuring 3.0 x 2.6 cm. The appendix is not visualized against a
background of normoactive bowel loops. No pericecal fluid collection at time of
examination.

IMPRESSION
Low density calculi lining the calyceal walls, both kidneys, non-obstructing at
present. Normal sized uterus with physiologic endometrium. Physiologic
appearance of left ovary. Right ovary not delineated. Non-specific cystic structure
within right adnexa. Considerations include: endometrioma, hemorrhagic cyst or
corpus luteum. Normal urinary bladder and abdominal aorta. Appendix is not
visualized against a background of normoactive bowel loops.
 Co-Management 3
Name Age/ Chief Clinical Impression Plan/ Final Diagnosis
Status Complaint
K, TPJ 25/S Hypogastric Pelvic Inflammatory - Labs: Whole
pain Disease Abdomen UTZ Plain,
TVS, Pap smear with
gram staining for CV
discharges, CBC,
Urinalysis, serum
creatinine, sodium,
potassium, serum
amylase and lipase,
SGPT-ALT

-Medications:
Tramadol HCL 50mg
IVTT, Cefuroxime 1.5g
IV ANST then 750mg
IVTT every 8 hours;
Clindamycin 900mg
IVTT every 8 hours
 URINALYSIS 07/10/2017
GRAM STAIN OF CV 07/10/17 3:43 PM
DISCHARGES 6:57 PM Physical Characteristics
FEW PUS CELLS
Color Yellow
MANY EPITHELIAL CELLS
MANY GRAM (+) BACILLI Transparency Clear
MANY GRAM (-) BACILLI pH 7.5
Specific Gravity 1.005
PROTHROMBIN TIME 07/10/17 Chemical Characteristics
6:07 PM
Blood 15
Patient 12.6
Microscopic Findings
Activity 112
Within normal limits
INR 0.94
Control 13.3
Control Activity 100 PREGNANCY TEST: NEGATIVE,
SPECIFIC GRAVITY 1.010
(TAKEN AT 6:53 PM, July 10)
 CBC 07/10/17
CBC 07/10/2017 5:08 PM
5:08 PM Differential Count
Blood Count
NEUTROPHIL 46.1
WBC 4.79
LYMPHOCYTE 36.1
RBC 4.03
MONOCYTE 8.4
Hemoglobin 11.8
EOSINOPHIL 7.7
Hematocrit 34.9
BASOPHIL 1.7
Platelet 282
Blood Indices
CLINICAL CHEMISTRY 07/10/17
MCV 86.6 6:57 PM
MCH 29.3 CREATININE 0.6
MCHC 33.8 SGPT-ALT 25
RDW 14.9 AMYLASE 52
PDW 11.1 LIPASE 167
MPV 10.2 SODIUM 126
POTASSIUM 3.6