IDRF TAMBONG | Diseases And Disorders

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  OSPITAL NG MAYNILA MEDICALCENTERDEPARTMENT OF SURGERY  President Quirino Avenue cor. Roxas Boulevard,   Malate, Manila, Philippines NAMEHERNANDEZ, RamonHOSPITAL NO. 1838522 ADDRESS  Tu, Batan!as AGE/SEX 5 #M DIAGNOSIS $drops o% the &al'ladder DATE OF ADMISSION 2#15#2 1( DOCTORS IN CHARGE )rs. &uera#*ele+#Alve+#)e eon#-a'unan CLERKS IN CHARGE  /s Arit, Bautista, 0oncepcion, stolas, -erin, &arcia, Montes Reason for referral: Post-op status, hypertension and seizure disorder.Referring Physician: ___________________________________________________ Receiving Physician: ____________________________________________________ Referring Department: Department of SurgeryReferring to: Department of Internal edicine Inte!e atmenta# Re$ea# Fom  This is a case o% a 5 #M ho cae in due to ri!ht upper 4uadrant pain. HISTORY OF PRESENT ILLNESS Patient non 0*) ith ri!ht sided residuals since 2 3 aintained on Aspirin 8 ! 6) and osartan 1 ! 6). Patientalso non ith 7ei+ure )isorder since 2 3 aintained on Pheno'ar'ital  ! 2 ta'lets B/). 3 ees PT0, patient experienced ri!ht upper 4uadrant pain (#1 , radiatin! to the 'ac. 9o %ever, no voitin!, no chan!e inBM, no :aundice. 9o other associated sptos. Patient sou!ht consult at a private M) here he as prescri'ed ith 0elexoci'2 ! ta' B/) %or pain and as advised to have a'doinal ultrasound. /n the interi, there as persistence o% interittent ri!ht upper 4uadrant pain hich as relieved ' tain! prescri'ededications. 1 da PT0, patient noted increased severit o% ri!ht upper 4uadrant pain ;%ro ( to <#1 = hence consult at our institution. PAST MEDICAL HISTORY  ;>= 0*) ith ri!ht sided residuals ;2 3, Batan!as=, aintained on Aspirin 8 ! 6). ;>= $pertension ? aintained on osartan1 !#ta' 6) and Metoprolol 1 !#ta' 6);>= 7ei+ure )isorder ;2 3, Batan!as= aintainedon Pheno'ar'ital  ! 2 ta's B/) ;ast Attac@)ece'er 2 15=;= )M;= BA;= Aller!ies to %ood#edication FAMILY MEDICAL HISTORY  ;>= $pertension;= )M PERSONAL SOCIAL HISTORY  5 pac ear soerAlcohol intae@ 1(5!#ee)enies dru! a'use PHYSICAL EXAMINATIONGenea# @Aae, conscious, coherent, not in cardiorespirator distressBP  13 #( $! $R  <( RR  21 cp Tep  3(C0 62 sat  <8D HEENT% Anicteric sclerae, pin palpe'ral con:unctiva, ;= nasoaural dischar!e, oist oral ucosa, ;= cervical lphadenopath, no tonsillopharn!eal con!estion C&e't an! L(n)'% 7etric chest expansion, ;= retractions, clear 'reath sounds Heat% Adnaic precordiu, noral rate, re!ular rhth, ;= ururs A*!omen % E+temte'% -lat, so%t, nontender, noroactive 'oel sound&rossl noral extreities, -ull and e4ual pulses, no edea, no canosis -ORKING DIAGNOSISH!o ' o$ t&e Ga#*#a!!ePLAN Patient aditted at roo E 2 under the service o% )rs. &uera#*ele+#Alve+#)e eon#-a'unan. 0onsent %or adission and ana!eent as secured. Patient placed on 9P6. /*-@ P977 1 x 1 cc#hr. Patient %or eer!enc open cholecstecto. Patient %or re%erral to the /nternal Medicine %or coana!eent. Re%erred and onitored accordin!l. NAMEHERNANDEZ, RamonHOSPITAL NO. 1838522 ADDRESS  Tu, Batan!as AGE/SEX 5 #M DIAGNOSIS $drops o% the &al'ladder DATE OF ADMISSION 2#15#2 1( DOCTORS IN )rs. &uera#*ele+#Alve+#)e eon#-a'unan  OSPITAL NG MAYNILA MEDICALCENTERDEPARTMENT OF SURGERY  President Quirino Avenue cor. Roxas Boulevard,   Malate, Manila, Philippines CHARGECLERKS IN CHARGE  /s Arit, Bautista, 0oncepcion, stolas, -erin, &arcia, Montes INTERDEPARTMENTAL REFERRAL FORMReceiving Copy Referring Physician: ___________________________________________________ Receiving Physician: ____________________________________________________ Referring Department: Department of SurgeryReferring to: Department of Internal edicine
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