OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: PENA, MAMETTA Age/Sex: 60/f Address: 2472 g. Del Pilar st. Singalong Manila Date of admission: July 20, 2007 Admitting Diagnosis: Acute Pancreatitis Carbuncle, Posterior aspect, Left thigh Residents in charge: Drs. Chan/Torre/Torres/Roxas/Estrada Clerk-in-Charge: Ocampo/Reloj/Rosarito
Hospital #: 1711520
24 HOUR HISTORY This is a case of a 60 year old female from Singalong Manila who came in due to abdominal pain. History of Present Illness One month PTA, patient has been having on and off pain; epigastric area, nonradiating, crampy, resolves spontaneously with pain severity of 4/10. Condition persisted for one month until… Few hours PTA, (+) epigastric pain, (+) radiating to the back described as boring in character with a pain severity of 7/10. (+) nausea, no fever, no cough, no DOB. Patient was brought to OMMC-ER and was subsequently admitted. Past Medical History No previous operation No DM No BA No HTN Family History Denies any heredofamilial disease Personal and Social History Nonsmoker Non alcoholic beverage drinker Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Gastrointestinal: (-) abdominal pain, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endo: (-) polyuria, (-) polyphagia, (-) polydipsia Rheuma: (-) joint pains Hema: (-) no easy bruisability Physical Examination: conscious, coherent, NICRD Vital Signs: BP: 150/90 HR: 82 RR: 19 Temp: 36.8 HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds, no crackles HEART: adynamic precordium, PMI 6th ICS LMCL, NRRR, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: grossly normal, full and equal pulses, no edema Assessment: Acute pancreatitis Carbuncle, posterior aspect, left thigh PLAN: Patient was admitted at the Infirmary and the admitting orders are as follows: TPR q shift, I and O monitoring, NPO temporarily except meds. IVF TF: PNSS 1L x 6. Diagnostics are as follows: CBC with PC, CXR-PA, 12-L ECG, BUN, Crea, RBS, FBS, HDL, LDL, UA, PFA, upright, SGPT, SGOT, Serum lipase, Chole, TG, HBT-UTZ. Therapeutics are the following: Omeprazole 40 mg TIV OD; Miperidine 25 TIV TID, if NA, may give Tramadol 50 mg TIV TID; Paracetamol 500 mg tab prn for fever > 38 C; Oxacillin, 1 g TIV q 6 ANST. WOF: abdominal pain, fever. VSq1 and UO monitoring.
COURSE IN THE WARDS: 1st hospital day, patient’s vital signs are as follows: BP 140/70, CR 78, RR 18, T 36.9. Patient was maintained on NPO. IVF was inserted – PNSS 1 L x 6, PNSS 1 L x 8. VSq2, abdominal status q2. WOF dyspnea, severe abdominal pain, fever. Ref.