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March 10, 2014 digital sign
Advised to bring two pairs of eyeglasses on board
done by Dr. Uy
Advised to bring two pairs of eyeglasses on board
advised on alcohol consumption in moderation
done by Dr. Uy
Advised to bring two pairs of eyeglasses on board
Advised cessation of smoking
done by Dr. Uy
Advised cessation of smoking
done by Dr. Uy
Advised cessation of smoking
advised on alcohol consumption in moderation
done by Dr. Uy
Advised
Advised
advised
done by
to bring two pairs of eyeglasses on board
cessation of smoking
on alcohol consumption in moderation
Dr. Uy
Advised on alcohol consumption in moderation
Done by Dr. Uy
done by Dr. Brigino
March 10, 2014
G, 0000, full term, NSD/ CS, no complication post delivery, ( )
Patient with no complaint of pain nor easy fatigability
of both lower extremities on long standing.
On pe- bilateral lower extremities: mild varicosities.
Rpt bp 00/00 mmHg, advised bp monitoring.
Rpt bp 00/00 mmHg,
advised to continue medication for hypertension and bp monitoring
Patient with no symptoms of orthopnea, dyspnea, chest pain
nor shortness of breath both at rest and during strenious
activity. On pe- cardiac: adynamic precordium,
normal rate at 00 bpm, regular rhythm, no murmur.
Patient with no complaint of pain nor easy fatigability
of both lower extremities on long standing.
On pe- bilateral lower extremities: mild varicosities.
Wears compression stockings at daytime.
Advised to continue wearing compression stockings
at daytime.
Ff-up for DRE (00/00/00)- good sphincter tone, no masses,
non-tender, (-)stool, (-) blood on examining finger;
prostate- soft, rubbery, non-tender, no masses,not enlarged.
Done by Dr. Brigino///
NAESS / KOTC (lumbosacral)
Patient has no urinary incontinence of irritative
symptoms; no back pain on prolonged standing,
bending over nor on carrying loads;
no trendelenberg sign; patient can hop and stand
on one foot with ease; can do serial squats with ease;
straight leg test is negative.
For Anglo
DRE: good sphincter tone, no masses, no tenderness, no blood,
no stool on examining finger.
Advised weight reduction and lifestyle modification.
For CCL
(-) Homan's Sign.
Acuity good to whispered voice.
Glasses
Advised to bring two pairs of eyeglasses on board.
Done by Dr. Brigino
Elevated BP mmHg, advised BP monitoring.
Advised regular intake of Anti-hypertensive medications
Advised to wear dark glasses for UV protection.
For HTN Patients
Known hypertensive since. Maintained on. With good compliance. With specialist c
learance.
For DM Patients
Known diabetic since. Maintained on. With good compliance. With specialist clear
ance.
FOR WOMEN:
GP (0000) s/p CS secondary to. Uncomplicated pregnancy.
GP (0000) s/p NSD. Uncomplicated pregnancy.
REPEAT PE:
Wound: Repeat PE: (+) granulation tissue (-) discharge
Dry, well coaptated wound,no dicharge noted
Repeat otoscopy: canals patent, no discharge, intact tympanic membrane, free fro
m infection
A > Impacted Cerumen AU, resolved
DRE: good sphincter tone, no masses, no tenderness, no blood, no stool on examin
ing finger.
Tight anal sphincter. Intact rectal vault. Upon palpation, no masses nor te
nderness noted.
Prostate smooth, rubbery ,slightly enlarged. (-) Hemorrhoids (-) anal skin
tag
(-) Blood PEF (+) Stool PEF
Medications
Atenolol (Therabloc) 50mg/tab 1 tablet once a day.
Amlodipine besylate 5mg/tab, 1 tablet once a day.
Amlodipine camsylate 5mg/tab, 1 tablet once a day.
Captopril (Capoten) 25mg/tab 1 tablet twice a day.
Irbesartan (Aprovel) 150mg/tab, 1 tablet once a day.
Lisinopril 10 mg/tab, 1 tablet once a day
Losartan Potassium + HCT (Combizar) 50/12.5 mg/tab 1 tablet once a day.
Losartan Potassium (Lifezar) 50mg/tab, 1 tablet once a day.
Metoprolol tartrate (Neobloc) 50mg/tab 1 tablet a day.
Verapamil hydrochloride + Trandolapril (Tarka) 180/2mg/tab, 1 tablet a day.
Felodipine (Versant-XR) 2.5mg/tab once a day.
Telmisartan + HCTZ (Micardis Plus) 40/12.5mg, 1 tab once a day
Known Diabetic since May 2008. Maintained on Metformin Hydrochloride 500mg/tab 1
tablet 3x a day and Gliclazide (Diamicron MR) 30mg/tab 1 tablet daily. With end
o clearance.
PE
Pinguecula, left, asymptomatic
Pinguecula, right, asymptomatic
Pinguecula, bilateral, asymptomatic
Pterygium, thin, slightly encroaching, right, asymptomatic. No treatment needed
at this time.
Pterygium, thin, non-encroaching, right, asymptomatic. No treatment needed at th
is time.
Pterygium, thin, non-encroaching, left, asymptomatic. No treatment needed at thi
s time.
Perforated tympanic membrane, 40%, central, right, no active infection at the ti
me of examination. No treatment needed at this time.
Perforated tympanic membrane, 40%, central, left, no active infection at the tim
e of examination. No treatment needed at this time.
Perforated tympanic membrane, bilateral, no active infection at the time of exam
ination. No treatment needed at this time.
Impacted cerumen, right. Advised ENT referral for aural irrigation.
Retained cerumen, left. Tympanic membrane not fully visualized. Advised ENT refe
rral for aural irrigation.
Grade hypertrophic tonsils, bilateral, non-hyperemic, non-exudative, asymptomati
c. No treatment needed at this time.
Fascial defect of umbilicus, less than 1 cm, asymptomatic. No surgical intervent
ion needed at this time.
2x2 cm mass, soft, non-tender, non-movable, right upper back. Diagnosis: Lipoma.
No surgical intervention needed at this time.
1x1 cm cystic mass, movable, non-tender,left testicular area, diagnosis: Epididy
mal cyst, asymptomatic. No surgical intervention needed at this time
Mild varicose veins, left popliteal area, asymptomatic. No surgical intervention
needed at this time. Advised to wear compression stockings.
Prominent superficial veins, left popliteal area, asymptomatic. Advised to wear
compression stockings.
Prominent superficial veins, bilateral popliteal area, asymptomatic. Advised to
wear compression stockings.
Varicocoele, left, mild, asymptomatic (has children). No surgical intervention n
eeded at this time.
1x1 cm cystic mass, movable, non-tender, right superior testicular area, asympto
matic. Diagnosis: Epididymal cyst. No surgical intervention needed at this time.
External hemorrhoids, non-thrombosed, asymptomatic. No surgical intervention nee
ded at this time.
Operations:
1990
s/p excision of cyst, left thigh ()
1990
s/p exploratory laparotomy due to stab wound, abdomen. ()
1990 - s/p Appendectomy ()
1990 - s/p Laparoscopic Appendectomy ()
1990
s/p varicoceolectomy, left ()
1990
s/p varicoceolectomy, right ()
2000
s/p tympanoplasty, right ()
1990
s/p removal of tattoo (laser), right deltoid ()
2001
s/p Open cholecystectomy, ()
2001
s/p Laparoscopic cholecystectomy, ()
2004
s/p Hemorrhoidectomy ()
2005
s/p Herniorrhaphy ()
2000
s/p fistulotomy ()
BMI
< 18.5 = Underweight
18.5 - 22.9 = HEALTHY WEIGHT
23 - 24.9 = Overweight
25 - 29.9 = Obese Class I
> 30 = Obese Class II
*
July 2009 - Allergic reaction to mussels. Consulted a dermatologist, given
cetirizine 10 mg/tab 1 tab once a day for 7 days and Dermasol cream, applied tw
ice a day. Patient had another bout of allergic reaction to mussels 3 days prior
to examination. Self medicated with Cetirizine 10 mg OD and Dermasol cream for
7 days, patient on his 4th day.
*
1 week PTC, patient developed colds; no cough, no fever, no joint pains; n
o consult done, self-medicated with Ambroxol 30mg/tab 1 tab BID x 3 days. Patien
t presently has nasal congestion with no other signs & symptoms.
*
1 week PTC, patient developed non-productive cough; no colds, no fever, no
joint pains moted; no consult done, self-medicated with Ambroxol 30mg/tab 1 tab
BID x 3 days. Patient presently reports occasional nasal congestion, with no ot
her signs & symptoms.
COUGH AND COLDS PREPARATION:
Dextromethorphan + phenylpropanolamine + Paracetamol (Decolsin), <Per cap Dextro
methorphan HBr 15 mg, phenylpropanolamine HCl 25 mg, paracetamol 325 mg.> 1 tab
3x a day for 7 days
Ambroxol 30mg/tab 1 tab BID x 3 days
Phenylephrine HCl 10 mg, paracetamol 500 mg (decolgen no drowse caplet)
1 cap every 6 hours
Paracetamol 500 mg, phenylephrine HCl 10 mg, chlorphenamine maleate 2 mg (decolg
en forte) 1 cap every 6 hours
Diagnosis: Upper respiratory tract infection
Prescribed Amoxicillin 500mg capsules 1 capsule q8 x 7 days. Lagundi tablet 1 ta
blet TID x 5 days.
Grade 2 Hypertrophic tonsils, bilateral, hyperemic and non-exudative, symptomati
c. Prescribed with Azithromycin 500mg/cap once a day for 3 days. Advised to come
back for repeat PE after treatment.
ATOPIC DERMATITIS
Cetirizine diHcl (Zyrtec) 10 mg/tab
1 tab OD x 1 wk
Betamethasone 250mcg + Dexchlorpheniramine maleate 2mg (Celestamine) 1 tab TID x
3 days
Betamethasone lotion to affected areas BID x 1 wk
DYSHIDROTIC ECZEMA
Petroleum jelly BID
TID
PE: Moist palm & soles with white-skin-colored scales
FOLLICULAR ECZEMA
Hydrocortisone cream (?)
Urea lotion (Nutraplus) 250 mL Apply BID-TID or PRN
INSECT BITES
Desonide (Desowen) cream 0.05% x 15g apply thinly BID x 3 days
IRRITANT CONTACT DERMATITIS
Betamethasone valerate (Betnovate) ointment 0.1% x 5g cream
Petroleum jelly TID & PRN
LICHEN SIMPLEX CHRONICUS
Fluocinonide (Lidex) ointment 0.05% x 5 g BID
ONYCHOMYCOSIS
KOH
PULSE TX ~ Itraconazole 100 mg/cap
1 treatment
2 caps BID x 1 wk
Fingernails ~ 2 pulse treatment
Toenails with or without fingernails involvement ~ 2 cap OD x 2 months
Topical Antifungal ~ Ketoconazole or Nizoral Cream 2% x (3.5g, 5g, 10g)
PSORIASIS
Clobetasol propionate (Dermovate) ointment 0.05% x 5g Apply BID to TID
Petroleum jelly BID & PRN
OR
Calcipotriol hydrate 50mcg + Betamethasone dipropionate 500 mcg (Daivobet) ointm
ent OD
Clobetasol 25g + vas alba qsad BID
SCALD BURN
Silver sulfadiazine (Flammazine) cream 1% micronized (5g, 20g, 50g, 500g) OD
SEBORRHEIC DERMATITIS
Diflucortolone valerate 1 mg + Isoconazole nitrate 10mg (Travocort) cream (5g, 1
0g) BID x 3-5 days
OR
Isoconazole nitroate (Travogen) cream 10mg/g x (5g, 10g) OD
AND
Ciclopirox olamine (Stieprox) 1.5% liquid shampoo (60 ml, 150 ml) every other da
y
Desonide (Desowen) cream 0.05% x 15g apply thinly BID
Desonide (Desowen) lotion 0.05% x 60 ml BID
Celeteque facial wash
TINEA CORPORIS / TINEA CRURIS
Griseofulvin fine particles (Grisovin
FP) 500 mg/tab 1 tab OD x 4 wks
Butenafine HCl (Funcid) cream 10g Apply BID x 4 wks
VERRUCA VULGARIS
Electrocautery
Fusidic acid 2% + Betamethasone valerate 0.1% (Fucicort) cream 5g BID
XEROTIC ECZEMA
Clobetasol propionate (Dermovate) ointment 0.05% x 5g Apply BID
Petroleum jelly BID & PRN
ALLERGIC RHINITIS
Fexofenadine HCl (Telfast) 120 mg/tab OD x 7 days
ACUTE OTITIS MEDIA
Co-trimoxazole: BID X 7 days
BACTRIM
Sulfamethoxazole (SMZ) 400mg + Trimethoprim TM 80mg
FORTE TAB: SMZ 800mg + TM 160mg
PHAREX CO-TRIMOXAZOLE tablets
400mg/80mg and 800/160 mg
Paracetamol 325mg + Phenylpropanolamine HCl 18mg (Ornex) 1 cap TID x 5 days
Hydrogen peroxide TID
ACUTE OTITIS EXTERNA
Betamethasone Na phosphate 0.1% + Gentamicin sulfate 0.3% (Garasone) otic drops
5 mL 3 gtts TID
Loratadine 5mg + Betamethasone 2500 mcg (Claricort) 1 tab BID x 10 days
ALLERGIC PHARYNGITIS
Loratadine 5mg + Betamethasone 2500 mcg (Claricort) 1 tab BID x 5 days after mea
ls
CHRONIC OTITIS MEDIA
Ciprofloxacin 500mg BID x 7 days
Ciprobay
Pharex
Fluocinolone acetonide 0.025% + Polymixin B Sulfate 10,000 IU + Neomycin Sulfate
3.5 mg (Synalar/Aplosyn) Otic Drops 5ml 3-4 gtts TID x 7 days
IMPACTED CERUMEN
Docusate NA (Otosol) otic drops 0.5% x 10 mL
Lie on the side turning the head side ways slightly towards the surface on which
you are lying, fill the ear canal & stay in this position for 4-5 mins then ins
ert a cotton wool plug. Repeat to the other ear if necessary
OR
Antipyrine 54 mg + Benzocaine 14 mg + Oxyquinoline sulfate 375 mcg (Auralgan) ot
ic drops
Instill into ear canal until filled, then moisten cotton pledget & insert into t
he meatus. Repeat 1-2 hourly until pain & congestion are relieved
OTITIS EXTERNA
Cloxacillin Na (Pharex) 500mg/cap q6 x 7days
Synalar / Aplosyn / Postotic otic drops 3-4 gtts TID x 7 days
POSTOTIC : Dexamethasone 1 mg + Neomycin Sulfate 3.5mg + Polymyxin B Sulfate 10,
000 IU
SINUSITIS
Augmentin 625 mg BID x 7 days
Amoxicillin trihydrate 520mg + Clavulanate K 125 mg
or
Cefalexin 500 mg q6 x 7 days
Sinupret tablet TID x 10 days
Radix gentianae 6 mg + Flores primulae cum calycibus 18 mg + Herba rumicis 18mg
+ Flores sambuci 18 mg + Herbe verbenae 18 mg
MITTENDORF DOT
Opacity in posterior lens capsule marking to site of attachment of atrophied emb
ryonic vasculature
CONJUNCTIVITIS
Tobramycin 0.3% + Dexamethasone 0.1% (Tobradex)
Eye drops 5mL 1-2 gtts TID-QID x 1 wk
Eye ointment 1-1.5 cm ribbon to conjunctiva sac TID to QID
EXTERNAL HORDEOLUM
Cloxacillin Na (Ritemed/Pharex) 500mg/cap 1 cap q6 x 7 days
OR
AUGMENTIN 1 g tab BID x 7 days
Moxifloxacin (Vigamox) eye drops 1 gtt q4 x 1 wk
DIFFUSE TOXIC GOITER PROBABLY GRAVE S DISEASE (CLINICALLY HYPERTHYROID)
? TSH
? T3
? T4
Methimazole 5 mg 2 tabs TID
Propanolol 40mg OD
RAI therapy
definitive management
?FT4
?TSH
L-thyroxine 25 mcg/tab OD
MIXED DYSLIPIDEMA
Fenofibrate (NUbrex) 300 mg/cap OD
RENAL STONES
Acalka 10mcg/cap 1 cap TID x 1 month
NaHCO3 650 mg/tab 1 tab TID x 1 month
OR
Rowatinex 1cap TID-QID
Pinene 31 mg + Camphene 1mg + Cineol 3 mg + Fenchone 4 mg + Borneol 10mg + Aneth
ol 4 mg + Olive oil 33 mg
Re-leaf forte 500mg/tab 1 tab TID
Sambong (Blumea balsamifera) powder leaves
ECT
Na thiopenthal
STROKE
ASA or Plavix
UNDESCENDED TESTES
Orchidopexy
PNEUMONIA
Azithromycin (Zithromax) 500 mg OD x 3 days
Repeat chest xray PA view after 1 week
OR
Clarithromycin 500 mg/tab 1 tab OD x 5 days
COUGH
Ambroxol HCl (Ambrolex) 20 mg/tab TID x 7 days
Acute & chronic disorders of the respiratory tract associated with pathologicall
y thickened mucus & impaired mucus transport
Butamirate citrate sustaine release tablet (Sinecod Forte) 50 mg TID x 5 days
Guaifenesin (Benadryl expectorant) 1-2 tsp q4
Loosens phlegm & thinks bronchial secretions to rid bronchial passages of bronch
osome mucus
Bromhexine HCl (Bisolvon) forte cap 16mg 1 cap TID
Abnormal mucus transport & impaired mucus transport
Erdostine (Ectrin) 300mg/cap 1 cap BID-TID
Acetylcysteine (FLuimucil) effervescent 600mg/tab 1 tab OD
(Ventolin expectorant) Guaifenesin 100 mg + Salbutamol 2 mg cap TID
Vitex negundo Linn. Lagundi leaf (Plemex forte), 600mg/5ml syrup, 5ml to be take
n 3-4 times
a day
FLU
Phenylpropanolomaine HCl 25mg + Chlorphenamine maleate 2mg + Paracetamol 500mg (
Bioflu)
Nasal congestion, headache, body aches & fever
TPHA REACTIVE
? in titer after 2 weeks of treatment (Repeat TPHA)
Doxycycline 100 mg/cap 2 caps BID x 2 wks
REACTIVE ARTHRITIS
Diclofenac Na 50 mg/tab 1
0
1
VESTIBULAR NEURONITIS
Medrol 4 mg/tab 1 tab TID x 1 wk
Duzaril tab 1 tab BID x 2 wks
Polynerv 500 mg/tab 1 tab BID
SKIN
Beclomethasone Dipropionate (Candibec) BID
ACUTE BRONCHITIS
Occasional rhonchi, normal CXR, 1 week cough
Levofloxacin 500mg/tab 1 tab OD x 7 days
REACTIVE RPR
Benzathine Pen G 2.4 M units IM weekly for 3 wks
Repeat RPR after 2 wks of treatment
Omental Patch closure (for ulcers)
Advised to bring two pairs of eyeglasses on board
done by Dr. Uy
Advised to bring two pairs of eyeglasses on board
advised on alcohol consumption in moderation
done by Dr. Uy
Advised to bring two pairs of eyeglasses on board
Advised cessation of smoking
done by Dr. Uy
Advised cessation of smoking
done by Dr. Uy
Advised cessation of smoking
advised on alcohol consumption in moderation
done by Dr. Uy
Advised
Advised
advised
done by
to bring two pairs of eyeglasses on board
cessation of smoking
on alcohol consumption in moderation
Dr. Uy
Advised on alcohol consumption in moderation
Done by Dr. Uy
done by Dr. Brigino
March 10, 2014
G, 0000, full term, NSD/ CS, no complication post delivery, ( )
Patient with no complaint of pain nor easy fatigability
of both lower extremities on long standing.
On pe- bilateral lower extremities: mild varicosities.
Rpt bp 00/00 mmHg, advised bp monitoring.
Rpt bp 00/00 mmHg,
advised to continue medication for hypertension and bp monitoring
Patient with no symptoms of orthopnea, dyspnea, chest pain
nor shortness of breath both at rest and during strenious
activity. On pe- cardiac: adynamic precordium,
normal rate at 00 bpm, regular rhythm, no murmur.
Patient with no complaint of pain nor easy fatigability
of both lower extremities on long standing.
On pe- bilateral lower extremities: mild varicosities.
Wears compression stockings at daytime.
Advised to continue wearing compression stockings
at daytime.
Ff-up for DRE (00/00/00)- good sphincter tone, no masses,
non-tender, (-)stool, (-) blood on examining finger;
prostate- soft, rubbery, non-tender, no masses,not enlarged.
Done by Dr. Brigino///
NAESS / KOTC (lumbosacral)
Patient has no urinary incontinence of irritative
symptoms; no back pain on prolonged standing,
bending over nor on carrying loads;
no trendelenberg sign; patient can hop and stand
on one foot with ease; can do serial squats with ease;
straight leg test is negative.
For Anglo
DRE: good sphincter tone, no masses, no tenderness, no blood,
no stool on examining finger.
Advised weight reduction and lifestyle modification.
For CCL
(-) Homan's Sign.
Acuity good to whispered voice.
Glasses
Advised to bring two pairs of eyeglasses on board.
Done by Dr. Brigino
Elevated BP mmHg, advised BP monitoring.
Advised regular intake of Anti-hypertensive medications
Advised to wear dark glasses for UV protection.
For HTN Patients
Known hypertensive since. Maintained on. With good compliance. With specialist c
learance.
For DM Patients
Known diabetic since. Maintained on. With good compliance. With specialist clear
ance.
FOR WOMEN:
GP (0000) s/p CS secondary to. Uncomplicated pregnancy.
GP (0000) s/p NSD. Uncomplicated pregnancy.
REPEAT PE:
Wound: Repeat PE: (+) granulation tissue (-) discharge
Dry, well coaptated wound,no dicharge noted
Repeat otoscopy: canals patent, no discharge, intact tympanic membrane, free fro
m infection
A > Impacted Cerumen AU, resolved
DRE: good sphincter tone, no masses, no tenderness, no blood, no stool on examin
ing finger.
Tight anal sphincter. Intact rectal vault. Upon palpation, no masses nor te
nderness noted.
Prostate smooth, rubbery ,slightly enlarged. (-) Hemorrhoids (-) anal skin
tag
(-) Blood PEF (+) Stool PEF
Medications
Atenolol (Therabloc) 50mg/tab 1 tablet once a day.
Amlodipine besylate 5mg/tab, 1 tablet once a day.
Amlodipine camsylate 5mg/tab, 1 tablet once a day.
Captopril (Capoten) 25mg/tab 1 tablet twice a day.
Irbesartan (Aprovel) 150mg/tab, 1 tablet once a day.
Lisinopril 10 mg/tab, 1 tablet once a day
Losartan Potassium + HCT (Combizar) 50/12.5 mg/tab 1 tablet once a day.
Losartan Potassium (Lifezar) 50mg/tab, 1 tablet once a day.
Metoprolol tartrate (Neobloc) 50mg/tab 1 tablet a day.
Verapamil hydrochloride + Trandolapril (Tarka) 180/2mg/tab, 1 tablet a day.
Felodipine (Versant-XR) 2.5mg/tab once a day.
Telmisartan + HCTZ (Micardis Plus) 40/12.5mg, 1 tab once a day
Known Diabetic since May 2008. Maintained on Metformin Hydrochloride 500mg/tab 1
tablet 3x a day and Gliclazide (Diamicron MR) 30mg/tab 1 tablet daily. With end
o clearance.
PE
Pinguecula, left, asymptomatic
Pinguecula, right, asymptomatic
Pinguecula, bilateral, asymptomatic
Pterygium, thin, slightly encroaching, right, asymptomatic. No treatment needed
at this time.
Pterygium, thin, non-encroaching, right, asymptomatic. No treatment needed at th
is time.
Pterygium, thin, non-encroaching, left, asymptomatic. No treatment needed at thi
s time.
Perforated tympanic membrane, 40%, central, right, no active infection at the ti
me of examination. No treatment needed at this time.
Perforated tympanic membrane, 40%, central, left, no active infection at the tim
e of examination. No treatment needed at this time.
Perforated tympanic membrane, bilateral, no active infection at the time of exam
ination. No treatment needed at this time.
Impacted cerumen, right. Advised ENT referral for aural irrigation.
Retained cerumen, left. Tympanic membrane not fully visualized. Advised ENT refe
rral for aural irrigation.
Grade hypertrophic tonsils, bilateral, non-hyperemic, non-exudative, asymptomati
c. No treatment needed at this time.
Fascial defect of umbilicus, less than 1 cm, asymptomatic. No surgical intervent
ion needed at this time.
2x2 cm mass, soft, non-tender, non-movable, right upper back. Diagnosis: Lipoma.
No surgical intervention needed at this time.
1x1 cm cystic mass, movable, non-tender,left testicular area, diagnosis: Epididy
mal cyst, asymptomatic. No surgical intervention needed at this time
Mild varicose veins, left popliteal area, asymptomatic. No surgical intervention
needed at this time. Advised to wear compression stockings.
Prominent superficial veins, left popliteal area, asymptomatic. Advised to wear
compression stockings.
Prominent superficial veins, bilateral popliteal area, asymptomatic. Advised to
wear compression stockings.
Varicocoele, left, mild, asymptomatic (has children). No surgical intervention n
eeded at this time.
1x1 cm cystic mass, movable, non-tender, right superior testicular area, asympto
matic. Diagnosis: Epididymal cyst. No surgical intervention needed at this time.
External hemorrhoids, non-thrombosed, asymptomatic. No surgical intervention nee
ded at this time.
Operations:
1990
s/p excision of cyst, left thigh ()
1990
s/p exploratory laparotomy due to stab wound, abdomen. ()
1990 - s/p Appendectomy ()
1990 - s/p Laparoscopic Appendectomy ()
1990
s/p varicoceolectomy, left ()
1990
s/p varicoceolectomy, right ()
2000
s/p tympanoplasty, right ()
1990
s/p removal of tattoo (laser), right deltoid ()
2001
s/p Open cholecystectomy, ()
2001
s/p Laparoscopic cholecystectomy, ()
2004
s/p Hemorrhoidectomy ()
2005
s/p Herniorrhaphy ()
2000
s/p fistulotomy ()
BMI
< 18.5 = Underweight
18.5 - 22.9 = HEALTHY WEIGHT
23 - 24.9 = Overweight
25 - 29.9 = Obese Class I
> 30 = Obese Class II
*
July 2009 - Allergic reaction to mussels. Consulted a dermatologist, given
cetirizine 10 mg/tab 1 tab once a day for 7 days and Dermasol cream, applied tw
ice a day. Patient had another bout of allergic reaction to mussels 3 days prior
to examination. Self medicated with Cetirizine 10 mg OD and Dermasol cream for
7 days, patient on his 4th day.
*
1 week PTC, patient developed colds; no cough, no fever, no joint pains; n
o consult done, self-medicated with Ambroxol 30mg/tab 1 tab BID x 3 days. Patien
t presently has nasal congestion with no other signs & symptoms.
*
1 week PTC, patient developed non-productive cough; no colds, no fever, no
joint pains moted; no consult done, self-medicated with Ambroxol 30mg/tab 1 tab
BID x 3 days. Patient presently reports occasional nasal congestion, with no ot
her signs & symptoms.
COUGH AND COLDS PREPARATION:
Dextromethorphan + phenylpropanolamine + Paracetamol (Decolsin), <Per cap Dextro
methorphan HBr 15 mg, phenylpropanolamine HCl 25 mg, paracetamol 325 mg.> 1 tab
3x a day for 7 days
Ambroxol 30mg/tab 1 tab BID x 3 days
Phenylephrine HCl 10 mg, paracetamol 500 mg (decolgen no drowse caplet)
1 cap every 6 hours
Paracetamol 500 mg, phenylephrine HCl 10 mg, chlorphenamine maleate 2 mg (decolg
en forte) 1 cap every 6 hours
Diagnosis: Upper respiratory tract infection
Prescribed Amoxicillin 500mg capsules 1 capsule q8 x 7 days. Lagundi tablet 1 ta
blet TID x 5 days.
Grade 2 Hypertrophic tonsils, bilateral, hyperemic and non-exudative, symptomati
c. Prescribed with Azithromycin 500mg/cap once a day for 3 days. Advised to come
back for repeat PE after treatment.
ATOPIC DERMATITIS
Cetirizine diHcl (Zyrtec) 10 mg/tab
1 tab OD x 1 wk
Betamethasone 250mcg + Dexchlorpheniramine maleate 2mg (Celestamine) 1 tab TID x
3 days
Betamethasone lotion to affected areas BID x 1 wk
DYSHIDROTIC ECZEMA
Petroleum jelly BID
TID
PE: Moist palm & soles with white-skin-colored scales
FOLLICULAR ECZEMA
Hydrocortisone cream (?)
Urea lotion (Nutraplus) 250 mL Apply BID-TID or PRN
INSECT BITES
Desonide (Desowen) cream 0.05% x 15g apply thinly BID x 3 days
IRRITANT CONTACT DERMATITIS
Betamethasone valerate (Betnovate) ointment 0.1% x 5g cream
Petroleum jelly TID & PRN
LICHEN SIMPLEX CHRONICUS
Fluocinonide (Lidex) ointment 0.05% x 5 g BID
ONYCHOMYCOSIS
KOH
PULSE TX ~ Itraconazole 100 mg/cap
1 treatment
2 caps BID x 1 wk
Fingernails ~ 2 pulse treatment
Toenails with or without fingernails involvement ~ 2 cap OD x 2 months
Topical Antifungal ~ Ketoconazole or Nizoral Cream 2% x (3.5g, 5g, 10g)
PSORIASIS
Clobetasol propionate (Dermovate) ointment 0.05% x 5g Apply BID to TID
Petroleum jelly BID & PRN
OR
Calcipotriol hydrate 50mcg + Betamethasone dipropionate 500 mcg (Daivobet) ointm
ent OD
Clobetasol 25g + vas alba qsad BID
SCALD BURN
Silver sulfadiazine (Flammazine) cream 1% micronized (5g, 20g, 50g, 500g) OD
SEBORRHEIC DERMATITIS
Diflucortolone valerate 1 mg + Isoconazole nitrate 10mg (Travocort) cream (5g, 1
0g) BID x 3-5 days
OR
Isoconazole nitroate (Travogen) cream 10mg/g x (5g, 10g) OD
AND
Ciclopirox olamine (Stieprox) 1.5% liquid shampoo (60 ml, 150 ml) every other da
y
Desonide (Desowen) cream 0.05% x 15g apply thinly BID
Desonide (Desowen) lotion 0.05% x 60 ml BID
Celeteque facial wash
TINEA CORPORIS / TINEA CRURIS
Griseofulvin fine particles (Grisovin
FP) 500 mg/tab 1 tab OD x 4 wks
Butenafine HCl (Funcid) cream 10g Apply BID x 4 wks
VERRUCA VULGARIS
Electrocautery
Fusidic acid 2% + Betamethasone valerate 0.1% (Fucicort) cream 5g BID
XEROTIC ECZEMA
Clobetasol propionate (Dermovate) ointment 0.05% x 5g Apply BID
Petroleum jelly BID & PRN
ALLERGIC RHINITIS
Fexofenadine HCl (Telfast) 120 mg/tab OD x 7 days
ACUTE OTITIS MEDIA
Co-trimoxazole: BID X 7 days
BACTRIM
Sulfamethoxazole (SMZ) 400mg + Trimethoprim TM 80mg
FORTE TAB: SMZ 800mg + TM 160mg
PHAREX CO-TRIMOXAZOLE tablets
400mg/80mg and 800/160 mg
Paracetamol 325mg + Phenylpropanolamine HCl 18mg (Ornex) 1 cap TID x 5 days
Hydrogen peroxide TID
ACUTE OTITIS EXTERNA
Betamethasone Na phosphate 0.1% + Gentamicin sulfate 0.3% (Garasone) otic drops
5 mL 3 gtts TID
Loratadine 5mg + Betamethasone 2500 mcg (Claricort) 1 tab BID x 10 days
ALLERGIC PHARYNGITIS
Loratadine 5mg + Betamethasone 2500 mcg (Claricort) 1 tab BID x 5 days after mea
ls
CHRONIC OTITIS MEDIA
Ciprofloxacin 500mg BID x 7 days
Ciprobay
Pharex
Fluocinolone acetonide 0.025% + Polymixin B Sulfate 10,000 IU + Neomycin Sulfate
3.5 mg (Synalar/Aplosyn) Otic Drops 5ml 3-4 gtts TID x 7 days
IMPACTED CERUMEN
Docusate NA (Otosol) otic drops 0.5% x 10 mL
Lie on the side turning the head side ways slightly towards the surface on which
you are lying, fill the ear canal & stay in this position for 4-5 mins then ins
ert a cotton wool plug. Repeat to the other ear if necessary
OR
Antipyrine 54 mg + Benzocaine 14 mg + Oxyquinoline sulfate 375 mcg (Auralgan) ot
ic drops
Instill into ear canal until filled, then moisten cotton pledget & insert into t
he meatus. Repeat 1-2 hourly until pain & congestion are relieved
OTITIS EXTERNA
Cloxacillin Na (Pharex) 500mg/cap q6 x 7days
Synalar / Aplosyn / Postotic otic drops 3-4 gtts TID x 7 days
POSTOTIC : Dexamethasone 1 mg + Neomycin Sulfate 3.5mg + Polymyxin B Sulfate 10,
000 IU
SINUSITIS
Augmentin 625 mg BID x 7 days
Amoxicillin trihydrate 520mg + Clavulanate K 125 mg
or
Cefalexin 500 mg q6 x 7 days
Sinupret tablet TID x 10 days
Radix gentianae 6 mg + Flores primulae cum calycibus 18 mg + Herba rumicis 18mg
+ Flores sambuci 18 mg + Herbe verbenae 18 mg
MITTENDORF DOT
Opacity in posterior lens capsule marking to site of attachment of atrophied emb
ryonic vasculature
CONJUNCTIVITIS
Tobramycin 0.3% + Dexamethasone 0.1% (Tobradex)
Eye drops 5mL 1-2 gtts TID-QID x 1 wk
Eye ointment 1-1.5 cm ribbon to conjunctiva sac TID to QID
EXTERNAL HORDEOLUM
Cloxacillin Na (Ritemed/Pharex) 500mg/cap 1 cap q6 x 7 days
OR
AUGMENTIN 1 g tab BID x 7 days
Moxifloxacin (Vigamox) eye drops 1 gtt q4 x 1 wk
DIFFUSE TOXIC GOITER PROBABLY GRAVE S DISEASE (CLINICALLY HYPERTHYROID)
? TSH
? T3
? T4
Methimazole 5 mg 2 tabs TID
Propanolol 40mg OD
RAI therapy
definitive management
?FT4
?TSH
L-thyroxine 25 mcg/tab OD
MIXED DYSLIPIDEMA
Fenofibrate (NUbrex) 300 mg/cap OD
RENAL STONES
Acalka 10mcg/cap 1 cap TID x 1 month
NaHCO3 650 mg/tab 1 tab TID x 1 month
OR
Rowatinex 1cap TID-QID
Pinene 31 mg + Camphene 1mg + Cineol 3 mg + Fenchone 4 mg + Borneol 10mg + Aneth
ol 4 mg + Olive oil 33 mg
Re-leaf forte 500mg/tab 1 tab TID
Sambong (Blumea balsamifera) powder leaves
ECT
Na thiopenthal
STROKE
ASA or Plavix
UNDESCENDED TESTES
Orchidopexy
PNEUMONIA
Azithromycin (Zithromax) 500 mg OD x 3 days
Repeat chest xray PA view after 1 week
OR
Clarithromycin 500 mg/tab 1 tab OD x 5 days
COUGH
Ambroxol HCl (Ambrolex) 20 mg/tab TID x 7 days
Acute & chronic disorders of the respiratory tract associated with pathologicall
y thickened mucus & impaired mucus transport
Butamirate citrate sustaine release tablet (Sinecod Forte) 50 mg TID x 5 days
Guaifenesin (Benadryl expectorant) 1-2 tsp q4
Loosens phlegm & thinks bronchial secretions to rid bronchial passages of bronch
osome mucus
Bromhexine HCl (Bisolvon) forte cap 16mg 1 cap TID
Abnormal mucus transport & impaired mucus transport
Erdostine (Ectrin) 300mg/cap 1 cap BID-TID
Acetylcysteine (FLuimucil) effervescent 600mg/tab 1 tab OD
(Ventolin expectorant) Guaifenesin 100 mg + Salbutamol 2 mg cap TID
Vitex negundo Linn. Lagundi leaf (Plemex forte), 600mg/5ml syrup, 5ml to be take
n 3-4 times
a day
FLU
Phenylpropanolomaine HCl 25mg + Chlorphenamine maleate 2mg + Paracetamol 500mg (
Bioflu)
Nasal congestion, headache, body aches & fever
TPHA REACTIVE
? in titer after 2 weeks of treatment (Repeat TPHA)
Doxycycline 100 mg/cap 2 caps BID x 2 wks
REACTIVE ARTHRITIS
Diclofenac Na 50 mg/tab 1
0
1
VESTIBULAR NEURONITIS
Medrol 4 mg/tab 1 tab TID x 1 wk
Duzaril tab 1 tab BID x 2 wks
Polynerv 500 mg/tab 1 tab BID
SKIN
Beclomethasone Dipropionate (Candibec) BID
ACUTE BRONCHITIS
Occasional rhonchi, normal CXR, 1 week cough
Levofloxacin 500mg/tab 1 tab OD x 7 days
REACTIVE RPR
Benzathine Pen G 2.4 M units IM weekly for 3 wks
Repeat RPR after 2 wks of treatment
Omental Patch closure (for ulcers)
