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Central Visayas Health Referral Summary

The patient, an 82-year-old female, was referred from Talisay District Hospital to Vicente Sotto Memorial Medical Center for further evaluation and management of multiple non-painful hematomas, body malaise, bone pains, and productive cough. Her medical history included hypertension but no other major illnesses. Physical examination was unremarkable except for the presence of multiple hematomas on her skin. Laboratory tests and imaging were performed and she was initially treated with antibiotics and other medications. Due to her symptoms, she was referred to a hematologist for further consultation and management of a possible blood disorder.

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1K views2 pages

Central Visayas Health Referral Summary

The patient, an 82-year-old female, was referred from Talisay District Hospital to Vicente Sotto Memorial Medical Center for further evaluation and management of multiple non-painful hematomas, body malaise, bone pains, and productive cough. Her medical history included hypertension but no other major illnesses. Physical examination was unremarkable except for the presence of multiple hematomas on her skin. Laboratory tests and imaging were performed and she was initially treated with antibiotics and other medications. Due to her symptoms, she was referred to a hematologist for further consultation and management of a possible blood disorder.

Uploaded by

RjPinat
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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  • Clinical Referral Form

CENTRAL VISAYAS HEALTH REFERRAL SYSTEM

Clinical Referral Form

Name of Referring Facility: Talisay District Hospital


Facility Contact #: (032) 273 3226 / (032) 273 3713
Address: San Isidro, City Of Talisay, Cebu
Referred to: Vicente Sotto Memorial Medical Center Department: ED Complex
Address: Sambag II (Pob.), Cebu City (Capital), Cebu
Date/Time Referred (ReCo): December 21, 2018 05:32 PM Date/Time Transferred:
Name of Patient: TOMASA MABIA PESTAÑAS Age: 82 Sex: Female Status: Married
Address: Cansojong, City Of Talisay, Cebu
PhilHealth Status: None PhilHealth # :
Case Summary (pertinent Hx/PE, including meds, labs, course etc.):
1 MONTH PTA ONSET OF ON AND OFF NON-PAINFUL HEMATOMAS WAS NOTED WHICH SPONTANEOUSLY
RESOLVES.
1 WEEK PTA ONSET OF BODY MALAISE/BONE PAINS. AROUND THIS TIME, ONSET OF PRODUCTIVE COUGH
WITH YELLOW SPUTUM WAS ALSO NOTED (-) FEVER. DAY PTA PERSISTENCE OF SYMPTOMS WERE NOTED,
SOUGHT CONSULT AND WAS ADVISED ADMISSION.

(+) HPN
(-) DM
(-) BA
(-) PREV ADMISSIONS/SURGICAL OPERATIONS

PHYSICAL EXAMINATION
GEN SURVERY: AWAKE, ALERT
SKIN: (+) MULTIPLE HEMATOMAS, SENILE TURGOR, WARM
C/L: ECE, CBS
CVS: AP, DHS
EXT: NO EDEMA, NO DEFORMITIES
MOTOR: 5/5 ON ALL

MEDS:
1. CEFUROXIME 750MG IV DRIP Q 8H (DAY 7)
2. NAC 600 MG /TAB, 1 TAB BID
3. AMLODIPINE 10MG, 1 TAB PO OD
4. LOSARTAN 50MG/TAB, 1 TAB PO BID
5. CELECOXIB 200MG/TAB, 1 TAB PO OD

LABS DONE:
CBC, PBS, UTZ WA, CXR PA, XRAY OF LUMBOSACRAL AREA, NA, K, CREA, BUA, FBS, LP, HBA1C- LAB
RESULTS ATTACHED

VITAL SIGNS
BP: 100/70
HR: 80
RR: 20
TEMP 36.5

Summary of ReCo (pls. refer to ReCo Guide in Referring Patients Checklist):


TRANSFER VIA AMBULANCE WITH AN ACCOMPANYING NURSE

Diagnosis/Impression:
R/O BLOOD DYSCRASIA, CAP-MR, HCVD, IMPAIRED FASTING GLUCOSE, OSTEOARTHRITIS OF LUMBAR
SPINE, OSTEOPOROSIS

Reason for referral:


FOR HEMATOLOGIST CONSULT/ CO-MANAGEMENT

Name of referring MD/HCW: Dr. MARIGOLD BAGABOYBOY ALBURO


Contact # of referring MD/HCW: 0942 494 6804
Name of referred MD/HCW- Mobile Contact # (ReCo):

CENTRAL VISAYAS HEALTH REFERRAL SYSTEM Clinical Referral Form Name of Referring Facility: Talisay District Hospital Facility
RR: 20 TEMP 36.5 Summary of ReCo (pls. refer to ReCo Guide in Referring Patients Checklist): TRANSFER VIA AMBULANCE WITH AN

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