ILOILO DOCTORS’ HOSPITAL, INC. West Avenue, Molo, Iloilo City Tel.No. (033) 337-7702 to 09 180 9001:2008 CERTIFIED Medical Records Department CLINICAL/MEDICAL ABSTRACT Name: DASKAL, SOCORRO BUENDIA Age: 80 years old _Sex: Female Civil Status: Widowed Address: Barangay Poblacion, Barotac Nuevo, lloilo ‘Ward/Rm.: Room 1 Second Floor Station Hospital No. 201709002478 Date Admitted: September 28, 2017 Date Discharge: _October 3, 2017 ‘Admitting Physician: Dr. Theresa Rubi Jamerlan Nadala, M.D. Final Diagnosis: Hepatic Malignancy with Intraabdominal Nodal Spread; Hypertensive Cardiovascular Disease; Cholecystolithiasis Brief Clinical History and Pertinent P.E.: CC: Abdominal pain History of present illness: S.weeks prior to admission when patient had acute onset of epigastric pain radiating to the left side of the abdomen associated occurring at no particular time of the day. 4 days prior to admission, above condition was now associated with loss of appetite and sensation of abdominal fullness but with no bowel movement or flatus_ Consult was sought and patient was prescribed with a suppository which eventually aided in defecating a brownish stool with normal caliber. Diagnostics requested and whole abdomen ultrasound showed mild hepatomegaly with a right hepatic mass, measuring 7.0 x 7.1 x 5.5 om (LxWAP) cholelithiasis with gallbladder sludge, thus admission was advised. Past Medical History: 2008: Quadruple Bypass and Ablation Surgery 2015: Cataract Surgery Known Hypertensive with maintenance medications Family History Hypertension on both sides of the family Personal History Non-Smoker, Non-Alcoholic Beverage Drinker Physical examination findings showed right hepatic lobe mass measuring 7 x § cm with abdominal distention and tendemess. Cardiac findings showed bradycardia at 55 beats /min normal rhythm. Other findings were unremarkable. Laboratory Findings: ECG: Sinus Bradycardia, Occasional Premature Atrial Contractions, Chest PA View X-ray: Pneumonitis, Paracardiac Area, Atherosclerotic Aorta, Sternotomy Wires In Situ CBC: Hgb- 122, HCT- 0.37, RBC- 4.25, WBC- 10.48, Segmenters- 76 %, Lymphocyte -17%, Eosinophil- 1%, Monocytes 6% and Platelet- increased. 10f3Blood Type: O Positive Bleeding time: 1'00° min., Clotting time: 15'00" min Prothrombin Time Activity: 77%, Normalized Ratio: 1,17 ‘Serum Creatinine: 114.79 from 146.85 umol/L, Serum Potassium: 3.38 mmol/L, ‘Serum Sodium: 142.00 mmol/L CA- 199: >500 U/ml, CEA: 18.10 ng/mL, AFP: 2.06 IU/mL Serum Amylase: 106.00 U/L, SGOT: 17.94 U/L, SGPT: 24.00 U/L. Serum Cholesterol: 3.80 mmol/L, Triglycerides: 1.88 mmol/L, HDL: 1.07 mmol/L, LDL: 1.88 mmollL, FBS: 6.55 mmollL, Whole Abdomen CT Scan with Contrast Hepatic Masses and Nodules. A Neoplastic Process is considered Left. Hepatic Lobe Cyst, Reidel’s lobe Extra_and Intra Hepatic Ductal Ectasia and a Slightly Dilated Pancreatic Duct, Gallbladder Lithiasis and ‘Sludge Formation, Paraaortic and Paracaval Lymphadenopathies, Course in the Ward: Diet: Initially placed on NPO but eventually was started on Soft Diet and progressed to Full Diet, \Venoclysis: DSLR 1Liter+ 20megs KCL alternating with DSNM 4Liter Initial rate was at 125cc/hr but was decreased to 80cc/hr Medications: 1. Vitamin K: 1 amp. IV Q8H 2. Dexlansoprazole (Dexilant): 60ma/cap, 1 cap OD 3. N-Acetylcysteine (Fiuimucil): 600ma/tab 1 tab in ¥4 glass water BID 4. Cefuroxime (Kefox): 750mq IV Q8H 5. Atorvastatin: 4Omg/tab, 1 tab OD at HS 6. Losartan: 100mg/tab, 1 tab OD. 7. Hydrochlorthiazide: 12.5majtab, 1 tab OD 8. Morphine Sulfate: 10ma/tab, %4 tab Q4H x 2 doses then %4 tab Q4H RTC Paracetamol. 500ma/tab, 1 tab Q8H 10. Metoclopramide : 5ma IV Q4H initially then was shifted to 10mg/tab, 1 tab TID 11. KCL tablet: 1 tab x 6 doses 12. Metronidazole (Bbraun): 500mg IV Q8H 13. Ketorolac (Toradol): 15mq IV Q8H 14, Nalbuphine: 2mg IV Q2H PRN for pain 15. Ramosetron: 300mg IV as stat dose 16. Bisacodryl: 2 tabs as stat dose 17. Morphine 5mq IV + 100CC PNSS x 20 co/hr then decreased to 10ce/hr 18, Nalbuphine 10mg IV + 100CC PNSS x 20 cc/hr 2 0f2Disposition: On the fifth day of hospitalization, patient was discharged per request for further work up and management at USA, Home Medication Dexlansoprazole (Dexilant): 60ma/cap, 1 cap OD pre breakfast Cefuroxime (Kefox): 500ma/tab, 1 tab BID for 5 days Losartan: 100ma/tab, 1 tab OD Atorvastatin: 40may/tab, 1 tab OD at HS Essential Phospholipids (Essentiale Forte) 1 cap OD Morphine Sulfate: 10majtab 1 tab every 8 hours and % tab Q4H as needed for pain Paracetamol: 500ma/tab, 1 tab Q8H Metoclopromide: 10mg/tab, 1 tab 30 minutes before meals, thrice a day for 2 days then as needed for nausea/ vomiting (same dose) Senna (Senokot): 1 tab daily SNOMRENH THERESA RUBI J. NADALA, M.D. Attending Physician ic. #: 55633 PTR #:5297173 30f3 Form-MOR026 Rev#-1 — January 18, 2013