Ospital ng Maynila Medical Center
Quirino Avenue corner Roxas Boulevard Manila, Philippines
Ospital ng Maynila Medical Center
Department of Surgery
Hospital No. 1957097 Ward: Surgery Ward Room 303
Name: Parena, Lenie Age/Sex: 17/F Address: Tondo, Manila Date Admitted: 23 Feb 2009 Admitting Diagnosis: T/c Acute Pancreatitis, Acute Appendicitis cannot be ruled out Residents-in-charge: Dr. Enriquez / Cruz / Gonzales / Malabanan / Lucero / Caravana Clerks-in-charge: JI Anicete / Baluyot / Barnes / Bautista / Belandres / Boado / Bognot Clinical Abstract This is a case of a 17 year old female from Tondo, Manila who came in due to abdominal pain.
History of Present Illness 1 week PTC, patient had on and off abdominal pain, colicky in character (-) consult (-) medications taken Few hours PTC, noted reappearance of abdominal pain, more severe, persistent, hence consult at our institution (+) fever thus consult Past Medical History (-) DM, (-) HPN, (-) BA, (-) allergy to food or drug Family History (-) heredofamilial diseases Personal/Social History Non-smoker, Non-alcoholic beverage drinker. Review of Systems Unremarkable. Physical Examination General: patient was conscious, coherent, oriented, not in cardiorespiratory distress. Vital Signs: BP 110/70, HR 82 bpm, RR 19 cpm, Temp 36.4°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, normoactive bowel sounds, (+) direct tenderness on RLQ and epigastric area. Extremities: grossly normal, good pulses, no cyanosis, no edema. Assessment: T/c Acute Pancreatitis, Acute Appendicitis cannot be ruled out Plan: Patient was admitted after consent was secured. Patient was put on NPO, hooked to IVF as follows: PNSS 1L to run for 8 hours. Medications were started: Tramadol 300mg + 500cc D5Wx 24 hours and Ranitididne 50mg TIV q8. NGT was inserted and kept open. IFC was inserted. Vital signs monitored every 4 hours.
Ospital ng Maynila Medical Center
Quirino Avenue corner Roxas Boulevard Manila, Philippines
Ospital ng Maynila Medical Center
Department of Surgery
Hospital No. 1957097 Ward: Surgery Ward Room 303
Name: Parenia, Lenie Age/Sex: 17/F Address: Tondo, Manila Date Admitted: 23 Feb 2009 Admitting Diagnosis: T/c Acute Pancreatitis, Acute Appendicitis cannot be ruled out Residents-in-charge: Dr. Enriquez / Cruz / Gonzales / Malabanan / Lucero / Caravana Clerks-in-charge: JI Anicete / Baluyot / Barnes / Bautista / Belandres / Boado / Bognot 24 Hour History This is a case of a 17 year old female from Tondo, Manila who came in due to abdominal pain.
History of Present Illness 1 week PTC, patient had on and off abdominal pain, colicky in character (-) consult (-) medications taken Few hours PTC, noted reappearance of abdominal pain, more severe, persistent, hence consult at our institution (+) fever thus consult Past Medical History (-) DM, (-) HPN, (-) BA, (-) allergy to food or drug Family History (-) heredofamilial diseases Personal/Social History Non-smoker, Non-alcoholic beverage drinker. Review of Systems Unremarkable. Physical Examination General: patient was conscious, coherent, oriented, not in cardiorespiratory distress. Vital Signs: BP 110/70, HR 82 bpm, RR 19 cpm, Temp 36.4°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, normoactive bowel sounds, (+) direct tenderness on RLQ and epigastric area. Extremities: grossly normal, good pulses, no cyanosis, no edema. Assessment: T/c Acute Pancreatitis, Acute Appendicitis cannot be ruled out Plan: Patient was admitted after consent was secured. Patient was put on NPO, hooked to IVF as follows: PNSS 1L to run for 8 hours. Medications were started: Tramadol 300mg + 500cc D5Wx 24 hours and Ranitididne 50mg TIV q8. NGT was inserted and kept open. IFC was inserted. Vital signs monitored every 4 hours. Course in the Wards: st On the 1 HD (2-23-09) patient was maintained on NPO. NGT was kept open. IFC was maintained. IVF and IV medications were continued. nd On the 2 HD (2-24-09) patient was maintained on NPO. Patient was requested for UTZ of Hepatobiliary Tree tomorrow without fail. IN the afternoon, patient had episode of abdominal pain, RUQ area. Patient was then given Tramadol 100mg TIV and tRamadol drip was continued 300mg +500cc x 24 hrs with BP precaution.patient rd On the 3 HD (2-24-09) patient was maintained on NPO. Patient was requested for UTZ of Hepatobiliary Tree
Ospital ng Maynila Medical Center
Quirino Avenue corner Roxas Boulevard Manila, Philippines
Ospital ng Maynila Medical Center
Department of Surgery
Hospital No. 1957097 Ward: Surgery Ward Room 303
Name: Parenia, Lenie Age/Sex: 17/F Address: Tondo, Manila Date Admitted: 23 Feb 2009 Admitting Diagnosis: T/c Acute Pancreatitis, Acute Appendicitis cannot be ruled out Residents-in-charge: Dr. Enriquez / Cruz / Gonzales / Malabanan / Lucero / Caravana Clerks-in-charge: JI Anicete / Baluyot / Barnes / Bautista / Belandres / Boado / Bognot Patients Discharge Summary This is a case of a 17 year old female from Tondo, Manila who came in due to abdominal pain.
History of Present Illness 1 week PTC, patient had on and off abdominal pain, colicky in character (-) consult (-) medications taken Few hours PTC, noted reappearance of abdominal pain, more severe, persistent, hence consult at our institution (+) fever thus consult Past Medical History (-) DM, (-) HPN, (-) BA, (-) allergy to food or drug Family History (-) heredofamilial diseases Personal/Social History Non-smoker, Non-alcoholic beverage drinker. Review of Systems Unremarkable. Physical Examination General: patient was conscious, coherent, oriented, not in cardiorespiratory distress. Vital Signs: BP 110/70, HR 82 bpm, RR 19 cpm, Temp 36.4°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, normoactive bowel sounds, (+) direct tenderness on RLQ and epigastric area. Extremities: grossly normal, good pulses, no cyanosis, no edema. Assessment: T/c Acute Pancreatitis, Acute Appendicitis cannot be ruled out Plan: Patient was admitted after consent was secured. Patient was put on NPO, hooked to IVF as follows: PNSS 1L to run for 8 hours. Medications were started: Tramadol 300mg + 500cc D5Wx 24 hours and Ranitididne 50mg TIV q8. NGT was inserted and kept open. IFC was inserted. Vital signs monitored every 4 hours. Course in the Wards: st On the 1 HD (2-23-09) patient was maintained on NPO. NGT was kept open. IFC was maintained. IVF and IV medications were continued. nd On the 2 HD (2-24-09) patient was maintained on NPO. Patient was requested for UTZ of Hepatobiliary Tree tomorrow without fail. IN the afternoon, patient had episode of abdominal pain, RUQ area. Patient was then given Tramadol 100mg TIV and Tramadol drip was continued 300mg +500cc x 24 hrs with BP precaution. rd On the 3 HD (2-25-09) patient was maintained on NPO then allowed to have soft diet after the evening rounds. NGT and IFC were removed at the end of the day. Patient was still for HBT-UTZ. Tramadol drip was continuously hooked. Vital signs were monitored every 6 hours. th On the 4 HD (2-26-09) patient was still for HBT-UTZ. Tramadol 100 mg TIV was given. th On the 5 HD (2-27-09) patient was still for HBT-UTZ. Present management was continued. th On the 6 HD (2-28-09) patient was allowed to have out on pass for the facilitation of ultrasound. th On the 7 HD (3-1-09) diet was maintained. IV Fluid and medications were continued. Abdominal status was monitored every 4 hours. Official Ultrasound result was followed-up. Vital signs were monitored every 4 hours. th On the 8 HD (3-2-09) patient was allowed to go home tomorrow to facilitate the ultrasound. Condition of the patient was explained to the mother. th On the 9 HD (3-3-09) patient was allowed to go home for facilitation of ultrasound.