Ospital ng Maynila Medical Center Department of Surgery Quirino Avenue cor Roxas Boulevard Manila, Philippines
Name: Pamintuan, Ronald Hospital No. 1520994 Age/Sex: 25/M Ward/Room No. Surgery Ward Address: 1238 San Andres Malate Manila Date Admitted: 26 Jan 2009 Admitting Diagnosis: Indirect Inguinal Hernia, Right 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 25 year old male who was brought in due to Inguinal mass, right History of Present Illness 15 years PTC, patient had on and off bulging mass on the left inguino-scrotal area, reducible. No consult was done no medications taken. 6 months PTC, there was persistence of on and off inguinoscrotal mass on the left. There was occasional pain. Patient then sought consult at Calamba Medical Center. With Diagnosis of IIH, left. Patient was advised for operation but was loss to follow-up. 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 frequency, no urgency Physical Examination General: patient was awake, coherent, oriented, not in cardiorespiratory distress. Vital Signs: CR 10/70 HR 81 bpm, RR 19cpm, 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, (+) tenderness on hypogastric and Right lower quadrant pain, (+) muscle guarding Extremities: grossly normal, no cyanosis, no edema Assessment: T/c Acute Appendicitis
Plan: For admission and management. Patient was admitted once consent for admission was done. Patient was put on NPO, and was hooked to IVF D5LR 1L x 8 hours. Medications prescribed were Cefoxitin 1 gm TIV q8 and Metronidazole 500 mg TIV q8. Patient was also ordered to be booked for ‘E’ appendectomy. Vital signs were monitored every 4 hours. Course in the wards: st On the 1 hospital day, patient opted to transfer to other institution.