Ospital ng Maynila Medical Center
Quirino Avenue corner Roxas Boulevard Manila, Philippines
Ospital ng Maynila Medical Center
Department of Surgery
Hospital No.1959838 Ward: Surgery Ward Room 306
Name: Navares, Zhinitchi Age/Sex: 1/M Address: 1095 Pat Antonio St. Sta. Mesa, Manila Date Admitted: 2 March 2009 Admitting Diagnosis: Indirect Inguinal Hernia, Right Physicians-in-charge: Dr. Cruz / Gonzales / Malabanan / Lucero / Caravana Clerks-in-charge: JI Anicete / Baluyut / Barnes / Bautista / Belandres / Boado / Bognot Patient Discharge Summary This is a case of a 1 year old male who was brought in due to inguinal mass on the right
History of Present Illness 8 months PTC, patient’s mother noted an inguinoscrotal mass on the right, soft, non-tender, reducible. Persistence of the mass prompted consult at a private MD and was diagnosed with IIH, right. Patient was then referred to this institution for further management. Past Medical History (-) BA, (-) DM, (-) HPN, (-) allergy to food or drug (-) previous hospitalization/ operation Family History Patient’s mother denies heredofamilial diseases Personal/Social History Complete EPI, can tolerate solids, can walk by himself Review of Systems Unremarkable. Physical Examination General: patient was awake, alert, not in cardiorespiratory distress Vital Signs: HR 96 bpm, RR 20cpm, Temp 37°C HEENT: anicteric sclera, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no nasoaural discharge, no cervical lymphadenopathy Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds. Cardio: Adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: slightly globular, flabby, NABS, soft, non-tender Extremities: No cyanosis, no edema, full and equal pulses Assessment: Indirect Inguinal Hernia, right
Plan: For Admission and management: Patient was admitted once consent for admission was secured. Diet was for age. Patient was for CBC with PC, UA, and Chest X-ray PA. Patient was for OR scheduling (Herniotomy). Vital signs were monitored every 4 hours. Course in the wards: On the 1st Hospital day, the patient was still for diet for age. CBC with PC, Urinalysis and Chest X-ray results were followed-up. X-ray plates were to be secured at bedside.
On the 2 Hospital day, Chest X-ray of the patient shows Pneumonia, bibasal. Patient was then referred to Pedia for comanagement. Patient was ordered for CP clearance on OPD basis and was allowed to go home Pedia wise given home medications: 1. Amoxicillin 250 mg/5 ml, 2.5 ml TID x 7 days, 2.) Multivitamins 0.5 ml OD, and 3.) Ascorbic Acid 0.5 ml OD. rd On the 3 Hospital day, patient was allowed to go home by Surgery Department. Oral medications to continue at home. Patient was asked to come back at OPD for follow-up. Well-advised.
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