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  OSPITAL NG MAYNILA MEDICALCENTERDEPARTMENT OF SURGERY  President Quirino Avenue cor. Roxas Boulevard,   Malate, Manila, Philippines NAMEREDILLAS, ChloeHOSPITAL NO. 2993642 ADDRESS 54 Area ! Parola, Binondo, Manila AGE/SEX 3 # ADMITTING DIAGNOSISSubdurl He! o! DATE OF ADMISSION #e$ruar% &9, 2&' PHYSICIANS#IN#CHARGE (rs. Mu)er *ele+ Alve+ (e eon #a$unan  $I%#IN#CHARGE  -s Arit, Bautista, !oncepcion, /stolas, #er0in, 1arcia, Montes CLINICAL A&STRACT  his is a case o a 3 # ho as $rouht in due to vehicular accident. 78 *ehicular accident(78 2 &' 2&'P78 !avite !it%78 38  PM HISTORY OF PRESENT ILLNESS & da% P!, patient as alleedl% hit $% a 0otorc%cle on patients shoulder and head. o 7!, no sei+ure episodes, nonausea, no vo0itin. Patient co0plained o headache $ut no 0edications ere iven and no consult souht.&: hours P!, there as persistence o headache hence patient as $rouht to 1at Andres ;ospital. Patient as re<uestedplain cranial ! scan hich revealed su$dural he0ato0a. Patient as advised transer to a $ier institution hence this consult andsu$se<uent ad0ission. PAST MEDICAL HISTORY   =>? 0easles, 0u0ps, ru$ella, BA o alleries to ood drus FAMILY MEDICAL HISTORY  =>? ;, BA, (M PHYSICAL EXAMINATIONGe'erl( Aa@e, not in distress, ood activit%, 1! &5 )* l S*+'%(HEENT Anicteric sclera, pin@ palpe$ral con)unctiva, =? contusion he0ato0a, &x& c0, =>? tonsillophar%neal conestion, =>? cervical l%0phadenopath% Che% 'd Lu'+%( %00etric chest expansion, =>? retractions, $ronchovesicular $reath sounds Her ( Ad%na0ic precordiu0, nor0al rate, reular rh%th0, =>? 0ur0urs Abdo!e' ( E re!* *e%(Neuro( #lat, nor0oactive $oel sounds, sot, nontender1rossl% nor0al extre0ities, ull e<ual pulses, =>? ede0a7riented to person, place, and ti0e!  C A!  C P/R 3>2 00!  * * C /7M intact! * C =? corneal reDex! * C no acial as%00etr% ! * C intact ross hearin! E E C uvula 0idline! E C e<ual shoulder shru! E C tonue 0idline ADMITTING DIAGNOSISSubdurl He! o!PLAN Patient as ad0itted at urer% ards roo0 4& under the service o (rs. Mu)er *ele+ Alve+ (e eon #a$unan. !onsent orthis ad0ission and 0anae0ent as secured. Patient as placed on (#A. *#8 P & x 45 cc hr. #or !B! ith P!, B ith R;, FA,P, P. Medications8 paraceta0ol &5 cc * Q6 PR or pain, cetriaxone 3 0 * Q&2. *ital sins and neuro vital sins ere0onitored ever% hour. Reerred accordinl%.  OSPITAL NG MAYNILA MEDICALCENTERDEPARTMENT OF SURGERY  President Quirino Avenue cor. Roxas Boulevard,   Malate, Manila, Philippines NAMEREDILLAS, ChloeHOSPITAL NO. 2993642 ADDRESS 54 Area ! Parola, Binondo, Manila AGE/SEX 3 # ADMITTING DIAGNOSISFINAL DIAGNOSISSubdurl He! o! Subdurl He! o! DATE OF ADMISSIONDATE OF DISCHARGE #e$ruar% &9, 2&'#e$ruar% 2, 2&' PHYSICIANS#IN#CHARGE (rs. Mu)er *ele+ Alve+ (e eon #a$unan  $I%#IN#CHARGE  -s Arit, Bautista, !oncepcion, /stolas, #er0in, 1arcia, Montes PATIENT DISCHARGE SUMMARY   his is a case o a 3 # ho as $rouht in due to vehicular accident. 78 *ehicular accident(78 2 &' 2&'P78 !avite !it%78 38  PM HISTORY OF PRESENT ILLNESS & da% P!, patient as alleedl% hit $% a 0otorc%cle on patients shoulder and head. o 7!, no sei+ure episodes, nonausea, no vo0itin. Patient co0plained o headache $ut no 0edications ere iven and no consult souht.&: hours P!, there as persistence o headache hence patient as $rouht to 1at Andres ;ospital. Patient as re<uestedplain cranial ! scan hich revealed su$dural he0ato0a. Patient as advised transer to a $ier institution hence this consult andsu$se<uent ad0ission. PAST MEDICAL HISTORY   =>? 0easles, 0u0ps, ru$ella, BA o alleries to ood drus FAMILY MEDICAL HISTORY  =>? ;, BA, (M PHYSICAL EXAMINATIONGe'erl( Aa@e, not in distress, ood activit%, 1! &5 )* l S*+'%(HEENT Anicteric sclera, pin@ palpe$ral con)unctiva, =? contusion he0ato0a, &x& c0, =>? tonsillophar%neal conestion, =>? cervical l%0phadenopath% Che% 'd Lu'+%( %00etric chest expansion, =>? retractions, $ronchovesicular $reath sounds Her ( Ad%na0ic precordiu0, nor0al rate, reular rh%th0, =>? 0ur0urs Abdo!e' ( E re!* *e%(Neuro( #lat, nor0oactive $oel sounds, sot, nontender1rossl% nor0al extre0ities, ull e<ual pulses, =>? ede0a7riented to person, place, and ti0e!  C A!  C P/R 3>2 00!  * * C /7M intact! * C =? corneal reDex! * C no acial as%00etr% ! * C intact ross hearin! E E C uvula 0idline! E C e<ual shoulder shru! E C tonue 0idline FINAL DIAGNOSISSubdurl He! o!PLAN Patient as ad0itted at urer% ards roo0 4& under the service o (rs. Mu)er *ele+ Alve+ (e eon #a$unan. !onsent orthis ad0ission and 0anae0ent as secured. Patient as placed on (#A. *#8 P & x 45 cc hr. #or !B! ith P!, B ith R;, FA,P, P. Medications8 paraceta0ol &5 cc * Q6 PR or pain, cetriaxone 3 0 * Q&2. *ital sins and neuro vital sins ere0onitored ever% hour. Reerred accordinl%. COURSE IN THE -ARDS & st  hospital da% =2>&9>&'?, patient had no loss o consciousness, no episodes o sei+ure. Patient had sta$le vital sins.Patient placed on diet appropriate or ae. *#8 P 36 0 x 45 cc hr. Medications8 &? Paraceta0ol &50 * <6h prn or pain 2?!etriaxone 30 * <&2h. Reerred and 0onitored accordinl%. Patient reerred to Pediatric (epart0ent or co>0anae0ent.  OSPITAL NG MAYNILA MEDICALCENTERDEPARTMENT OF SURGERY  President Quirino Avenue cor. Roxas Boulevard,   Malate, Manila, Philippines 2 nd  hospital da% =2>2>&'?, patient had no loss o consciousness, no episodes o sei+ure. Patient had sta$le vital sins.Patient placed on diet appropriate or ae. Patient or dischare and to ollo>up at urer%>7P( at March & 2&' ith oGcial !scan. NAMEREDILLAS, ChloeHOSPITAL NO. 2993642 ADDRESS 54 Area ! Parola, Binondo, Manila AGE/SEX 3 # ADMITTING DIAGNOSISFINAL DIAGNOSISSubdurl He! o! Subdurl He! o! DATE OF ADMISSIONDATE OF DISCHARGE #e$ruar% &9, 2&'#e$ruar% 2, 2&' PHYSICIANS#IN#CHARGE (rs. Mu)er *ele+ Alve+ (e eon #a$unan  $I%#IN#CHARGE  -s Arit, Bautista, !oncepcion, /stolas, #er0in, 1arcia, Montes PATIENT DISCHARGE INSTRUCTIONTAE HOME MEDICATIONS. Co#!o*0l1 23.4!+/4!L FM7M 1 3 0 HA(A : A 7RA A 77B 1 ' ARAI 3. Pr0e !ol 345!+/4!L %6ru7 2!L 89h :or 7*' FM7M 1 3 0 HA(A 6 A 7RA HAPA1 FMAAH A1 F7 FOLLO-#UP MA1 #77I>FP A FR1/RJ 7P( A MAR!; &, 2&' (AA A1 ABRA!, P(, A R//A PA AR A1 7##!A ! !A1A1 1A A(R/.
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