Ospital ng Maynila Medical Center Department of Surgery Quirino Avenue cor Roxas Boulevard Manila, Philippines
Name: Lorenzana, Jesus Hospital No. 1941429 Age/Sex: 54/M Ward/Room No. Surgery Ward Address: Atenicio Moncada, Tarlac Date Admitted: 20 Jan 2009 Admitting Diagnosis: Incarcerated IIH, Left Physicans-in-charge: Dr. Cruz/ Gonzales/ Malabanan/ Jawali/ Caravana Clerks-in-charge: JI Anicete/ Baluyut/ Barnes/ Bautista/ Belandres/ Boado/ Bognot Patient Discharge Summary
This is a case of a 54 year old male who was brought in due to inguinoscrotal mass, left. History of Present Illness 10 years PTA, patient noted on and off bulging mass on his left inguinoscrotal region with associated occasional pain. The mass is reducible when lying down. No consultation was made. Few hours PTA, there was increased in size of the mass, non-reducible, hence consultation was then made. Past Medical History No hypertension, no DM, no PTB, no asthma, no allergies, no goiter No previous hospitalization/operation Family History No hypertension, no DM, no PTB, no asthma, no goiter, no PTB Personal/Social History (+) smoker (-) alcoholic drinking Review of Systems: No headache, no BOV No cough, no dyspnea No chest pain, no palpitations No polyphagia, no polydipsia, no polyuria No dysuria, no urgency Physical Examination General: patient was awake, coherent, oriented, not in cardiorespiratory distress. Vital Signs: CR 110/70 HR 81 bpm, RR 17cpm, Temp 36.9°C HEENT: anicteric sclerae, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no nasoaural discharge. Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds. Cardio: Adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: Flat, NABS, soft, non-tender Genitals: (+) Inguinoscrotal mass, left Extremities: grossly normal, no cyanosis, no edema Assessment: Incarcerated IIH, Left
Plan: For admission and management. Patient was admitted once consent for admission was done. Patient was allowed for any diet then NPO post-midnight. Laboratory examinations requested were CBC, Urinalysis, Chest X-ray, 12L-ECG. He was also scheduled for ‘E’ Herniorrhaphy. Vital signs were monitored every 4 hours.
Course in the wards: st On the 1 hospital day, patient was operated. Cefazolin was given 1 gm TIV. He was then transferred to ward after recovery. nd On the 2 hospital day, patient was allowed to go home after the rounds with the consultant. Daily wound care was advised to be done at home.