De Guzman_ Shiela

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					Ospital ng Maynila Medical Center DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY (ENT-HNS) Quirino Avenue corner Roxas Boulevard Malate, Manila

Patient’s Name: De Guzman, Shiela N. Age/Sex: 16/F Admitting Diagnosis: Chronic Otitis Media, AU Physicians–in-charge: Drs. Samson/So/Del Valle/Ricardo/Tolentino/Salvador/Vidanes/Regino/Catignas Clerks-in-charge: Fabian/Ilarde/Ingles/Item/Junsay

Hospital No. 1498997

CLINICAL ABSTRACT

This is a case of a 16 year old female who came in due to ear pain, Right. History of Present Illness 10 years PTC, there was ear discharge and ear pain. There was no associated cough and colds, no tinnitus, no diarrhea, no vomiting. Few days PTC, there was persistence of above signs and symptoms which prompted consult at ENT-OPD of this institution. Past Medical History (+) previously admitted at UST hospital for ear infection when she was 6 y/o. No previous diseases. Family History: (-) HPN, (-) DM, (-) heart disease, (-) asthma, (-) kidney disease, (-) liver disease, (-) lung disease – PTB (-) goiter Personal/ Social History Non-smoker, non alcoholic beverage drinker Review of Systems General: no fever, no easy fatigability, no weight loss Skin: no skin lesion, no pruritus HEENT: no headache, no blurring of vision, no eye pain, no eye discharge, no excessive lacrimation, no vertigo, no colds Respiratory: no cough, no difficulty of breathing, no colds, no hemoptysis Cardiac: no chest pain, no orthopnea Gastrointestinal: no nausea, no vomiting, no abdominal pain, no change in bowel habit Genitourinary: no dysuria, no oliguria, no hematuria, no polyuria Hematology: no easy bruisability or bleeding, no pallor Endocrinology: no polyuria, no polyphagia, no polydipsia; no heat/cold intolerance Musculoskeletal: no joint pains Neuro: no LOC, no convulsion, no seizures Physical Examination General: conscious, coherent, not in cardio-respiratory distress Vital Signs: BP: 110/70 HR: 60 bpm RR: 20 cpm Temp: 37.0°C Weight: 51kg EYES: pink palpebral conjunctivae, anicteric sclera, PERTL 2-3 mm CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds HEART: adynamic precordium, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, non-tender EXTREMITIES: grossly normal, full and equal pulses, no cyanosis, no edema

Physical Exam of ENT:

(+)Impacted cerumen (+) Blood clots (-) tragal tenderness

septum midline, (-) mass, (-) congestion (-) gross deformity (-) discharge

(-) mass (-) CLAD

Uvula midline (-) TPC (-) ulcer (-) mass

ASSESSMENT: Chronic Otitis Media, AU PLAN: For admission For Mastoidectomy with tympanoplasty, AS


				
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posted:7/3/2009
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