PATIENT CARE RECORD

Patients name: S.R. Room no: 221B

Ward: FSW

Date:

Chief Complaint: Epigastric pain Diagnosis: Choledochal cyst type 1 Surgery: Excision odf
Choledochal cyst, Cholecystectomy followed by Roux-en-Y Hepaticojejunostomy
A. Health History
I.
Biographical data
Age: 20
Sex: Female Citizenship: Filipino Religion: Iglesia ni Cristo
Birthdate: 09/28/1995
Civil Status: Single Educ. Attainment: High Schoo
Graduate
Address: 8 Gasan St., Masambong, Quezon City
II.
History of Present Illness:
Two weeks prior to admission, patient experienced burning and squeezing
epigastric pain, graded10/10, radiating to the back, accompanie by vomiting,
bilious, amounting to 1 cup, anorexia, chills, body malaise and cold-clammy
extremities. Patient said to be self-medicated with Omeprazole 40mg/tab and
provides no relief of pain. Persistent of symptoms showed with episodes of vomiting
and a passage of tea-colored urine and anorexia. She was first consulted to the
nearest hospital near their house where she was given Omeprazole. She underwent
whole abdominal ultrasound and revealed biliary ectasia, choledochal cysts and
intrahepatic stones and negative KUB and Pelvic sonography. She was then later
transferred to USTH and was prescribed with Algesia.
One day prior to admission, she consulted at UST surgery OPD where assessment
was Choledochal cyst. Serum Na and K levels were low, MRCP was requested and
then advised admission.
III.
Past Health History
Patient has no any medical history of DM, Hypertension, Asthma, Allergy nor cardiac
disease. Patient has previous hospitalizations last 2004 due to Peptic Ulcer Disease.
She wasnt able to recall her medications.
IV.
Family Health History
According to the Patient, there are no history of major illnesses in her family.
Negative for DM, HPN, CANCER, MI, goiter and asthma

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