OSPITAL NG MAYNILA MEDICAL CENTER

Department of SURGERY
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

Name : ARCE, MESIASH ZARATE Hospital : 76859

Number
Address : 3174 Reposo St. Sta. Mesa, Manila Age/Sex : 21/M
Date of : 5/22/20 Time of : 10:45 PM
Admission Admission
Date of : 06/02/2020 Time of 5:00 PM
Discharge Discharge
Admitting : TO CONSIDER AMOEBIC LIVER DISEASE
Diagnosis
Final Diagnosis : HEPATIC ABSCESS
Physicians-in- : Drs. Alvez/De Leon/Opano/Tesil/Bautista, Gaspillo Specialty : SURGERY
Charge
PGI-in-Charge : PGI Sasa
Clerk-in-Charge :

REASON FOR ADMISSION: This is a case of a 21, M who came in due to abdominal pain.

HISTORY OF PRESENT ILLNESS

3 days prior to consult, patient experienced abdominal pain, 5-6/10, stabbing, localizing to the RUQ. This is
associated with fever, tea-colored urine and jaundice. No acholic stool, no nausea and vomiting. No other associated
symptom noted. Patient consulted at a private hospital and ruling out acute appendicitis. Due to financial constraint opted to
transfer to our institution.

PAST MEDICAL HISTORY Childhood illnesses

Diabetes Mellitus
Asthma
Previous operation
Previous hospitalization
Allergies to food/drug

FAMILY HISTORY PERSONAL AND SOCIAL HISTORY

HTN - maternal Non-smoker
No DM Non-alcoholic beverage drinker
No BA Denies illicit drug use
No CVD

REVIEW OF SYSTEMS

PERTINENT SIGNS AND SYMPTOMS ON ADMISSION (Put an “x” Mark if present):

Altered mental Diarrhea Hematemesis Palpitations
sensorium
Abdominal Dizziness Hematuria X Seizures
cramp/pain
Anorexia Dysphagia Hemoptysis Skin rashes
Bleeding gums Dyspnea Irritability Stool, bloody/black
tarry/mucoid
Body weakness Dysuria Jaundice X Sweating
Blurring of vision Epistaxis Lower extremity edema Urgency
Chest pain/discomfort Fever Myalgia Vomiting
Constipation Frequency of urination Orthopnea Weight loss
Cough Headache Abdominal Pain X Others:

PHYSICAL EXAMINATION AS OF ADMISSION

Put an “x” Mark if present
General Survey Awake and alert X Altered sensorium Weight:
Others:
Vital signs BP: 120/70 HR: 88 RR: 18 Temp: 37.7

CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ Date: June 2, 2020

Signature over Printed Name of Attending Health Care Professional
 OSPITAL NG MAYNILA MEDICAL CENTER
Department of SURGERY
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

HEENT Essentially X Abnormal pupillary Cervical Dry mucous

normal reaction Lymphadenopath membrane
y
Icteric sclerae Pale conjunctivae Sunken eyeballs Sunken fontanelle
Others: Anicteric sclera, pink palpebral conjunctiva
CHEST/LUNGS Essentially X Asymmetrical chest Decreased breath Wheezes
normal expansion sounds
Lump/s over Rales/Crackles/Ron Intercostal
breast(s) chi rib/Clavicular
retraction
Others: Normal rate, Symmetric chest expansion, clear breath sounds
CVS: Essentially X Displaced apex beat Heaves and/or Pericardial bulge
normal thrills
Irregular rhythm Muffled heart Murmur
sounds
Others: Adynamic precordium, normal rate, regular rhythm
Abdomen: Essentially Abdominal rigidity X Abdomen Hyperactive bowel
normal tenderness sounds
Others: Flat Soft, non-distended abdomen, tender, RUQ, no guarding
GU (IE): Essentially X Blood stained in Cervical dilatation Presence of
normal exam finger abnormal discharge
Others:
Skin/Extremitie Essentially X Clubbing Cold clammy skin Cyanosis/mottled
s: normal skin
Edema/swelling Decreased mobility Pale nailbeds Poor skin turgor
Rashes/petechi
ae
Others: Full equal pulses, CRT < 2 seconds, (+) jaundice, (-) edema, (-) cyanosis
NEURO-EXAM Essentially X Abnormal gait Abnormal position Abnormal/decrease
normal sense d sensation
Abnormal Poor/altered Poor muscle Poor coordination
reflex(es) memory tone/strength
Others:

Referred from another health care Name of Originating HCI:

institution (HCI)? If yes, specify
reason:

COURSE IN THE WARD (Attach photocopy of laboratory/imaging results)

Date DOCTOR’S ORDER
5/22 Admit patient at the surgery ward under the service Drs. Alvez/De Leon/Opano/Tesil/Bautista, Gaspillo. Secure
consent for admission. NPO. IVF: PLR 1L x 125 cc/hr, Dx: CBC PC, UA, BUN, Crea, Na K Cl, CXR PA, 12L
ECG, TB B1 B2, AST/ALT, ALP, Hepa Profile, WAB CT Scan, PT/PTT. Meds: Omeprazole 40 mg TIV OD,
Ceftriaxone 1 gm TIV q12, Metronidazole 500 mg TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol
50 mg TIV q8 PRN for pain. Serial Abdominal Examination q4. Monitor VSQ1. Refer.
5/23 Maintain on NPO. IVF: PLR 1L x 125 cc/hr, Dx: Still for CBC PC, CXR PA, 12L ECG, TB B1 B2, WAB CT Scan,
PT/PTT. Meds: Omeprazole 40 mg TIV OD, Ceftriaxone 1 gm TIV q12, Metronidazole 500 mg TIV q8,
Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for pain. Serial Abdominal Examination
q4. Monitor VSQ1. Refer.
5/24 May have clear liquids. IVF: PLR 1L x 125 cc/hr, Dx: Follow-up pending labs, WAB CT Scan Official result. Meds:
Omeprazole 40 mg TIV OD, Ceftriaxone 1 gm TIV q12, Metronidazole 500 mg TIV q8, Paracetamol 600 mg TIV
q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for pain. Serial Abdominal Examination. Monitor VSQ1. Refer.
5/25 May have full diet. IVF: to consume then heplock, Dx: Follow-up WAB CT Scan Official result. Meds: Ceftriaxone
1 gm TIV q12, Metronidazole 500 mg TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8
PRN for pain, discontinue omeprazole. Serial Abdominal Examination. Monitor VSQ4. Refer.
5/26 Diet as tolerated. IVF: Heplock, Dx: Follow-up WAB CT Scan Official result. Meds: Ceftriaxone 1 gm TIV q12,
Metronidazole 500 mg TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for pain.
Serial Abdominal Examination. Monitor VSQ4. Refer.
5/27 Diet as tolerated. IVF: Heplock, Dx: Official CT Scan. Meds: Ceftriaxone 1 gm TIV q12, Metronidazole 500 mg
TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for pain. Serial Abdominal
Examination. Monitor VSQ4. Refer.
CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ Date: June 2, 2020

Signature over Printed Name of Attending Health Care Professional
 OSPITAL NG MAYNILA MEDICAL CENTER
Department of SURGERY
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

5/28 Diet as tolerated. IVF: Heplock, Dx: Official CT Scan. Meds: Ceftriaxone 1 gm TIV q12, Metronidazole 500 mg
TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for pain. Serial Abdominal
Examination. Monitor VSQ4. Refer.
5/29 Diet as tolerated. IVF: Heplock, Dx: Official CT Scan. Meds: Ceftriaxone 1 gm TIV q12, Metronidazole 500 mg
TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for pain. Serial Abdominal
Examination. Monitor VSQ4. Refer.
5/30 Diet as tolerated. IVF: Heplock, Dx: Official CT Scan. For Liver Ultrasound. Meds: Ceftriaxone 1 gm TIV q12,
Metronidazole 500 mg TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for pain.
Serial Abdominal Examination. Monitor VSQ4. Refer.
5/31 Diet as tolerated. IVF: Heplock, Dx: For Liver Ultrasound today, Official CT Scan. Meds: Ceftriaxone 1 gm TIV
q12, Metronidazole 500 mg TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for
pain. Serial Abdominal Examination. Monitor VSQ4. Refer.
06/01 Diet as tolerated. IVF: Heplock, Dx: Facilitate Liver Ultrasound, Official CT Scan. Meds: Ceftriaxone 1 gm TIV
q12, Metronidazole 500 mg TIV q8, Paracetamol 600 mg TIV q6 PRN for pain, Tramadol 50 mg TIV q8 PRN for
pain. Serial Abdominal Examination. Update PDS. Monitor VSQ4. Refer.
06/02 May go home. Cefuroxime 500 mg/tab q8 for 8 weeks, Metronidazole 500 mg/tab q8 for 8 weeks, Paracetamol +
Tramadol 325 + 37.5 mg/tab q8 as needed for pain. Follow-up at Surgery OPD/ER. Well-advised.

OUTCOME OF TREATMENT (Put an “x” Mark if present)

Improved X HAMA: Expired Absconded: Transferred Specify reason:

: : :

LABORATORY FLOWSHEET

Hematology 5/18 5/22 5/30 Urinalysis 5/18 HEMA/COAGULATION 5/24

WBC 17.98 16.69 16,32 Dark PT 15.1 s
Color
Neutrophils 80.66 70.18 75.02 Yellow Protime % Activity 77 %
Lymphocytes 8.68 16.51 12.80 Transparency Turbid INR 1.2
Monocytes 9.02 8.53 7.25 Blood - aPTT 28.6
Eosinophils 1.60 3.54 4.28 Bilirubin -
Basophils 0.04 1.22 0.64 Urobilinogen -
RBC 4.64 4.94 4.95 Ketone -
HEPATITIS TEST (05/22)
Hgb 13.5 13.9 14.1 Protein +2
HBsAg 0.22 Non-reactive
Hct 40.0 39.6 39.1 Nitrite -
Anti-HBS 0.00 Non-reactive
MCV 86.3 80.2 79.0 Glucose Negative
Anti-HBc Total 0.23 Non-reactive
MCH 29.0 28.1 28.4 pH 6.0
Anti – HBc Igm 0.11 Non-reactive
MCHC 33.7 35.0 36.0 Specific Gravity 1.030
HBeAg 0.338 Non-reactive
RDW- CV 12.6 10.1 9.8 Leukocytes -
Anti-HBE 1.72 Non-reactive
Platelet 239 373 604 Epithelial cells Few
Anti-hav IgM 0.11 Non-reactive
Mucus thread Many
Anti - HCV 0.16 Non-reactive
Amorphous
Occasional
urates
WBC 0-2
RBC 0-2
BLOOD CHEMISTRY 5/18
Ultrasound of the Liver136.8
(06/01/20) Bacteria Few
Na
Findings
K compatible with hepatic
3.7 abscess,
histopathologic
Cl correlation104.0
suggested as
clinically warranted
5/20
Creatinine 73
eGFR 127.78 mL/min
PATIENT DISCHARGE INSTRUCTIONS:
5/22
AST 73
ALT 147
ALP 196
Take Home Medications:

Cefuroxime 500 mg/tab

Uminom ng isang tableta kada-8 oras sa loob ng 8 (walong) linggo

CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ Date: June 2, 2020

Signature over Printed Name of Attending Health Care Professional
 OSPITAL NG MAYNILA MEDICAL CENTER
Department of SURGERY
President Quirino Avenue cor. Roxas Boulevard,
Malate, Manila, Philippines

CLINICAL ABSTRACT – PATIENT DISCHARGE SUMMARY

Metronidazole 500 mg/tab

Uminom ng isang tableta kada-8 oras sa loob ng 8 (walong) linggo

Paracetamol + Tramadol, 325 + 37.5 mg/tab

Uminom ng isang tableta kada-8 oras para sa pagkirot ng sikmura.

Mag follow-up sa Surgery-ER matapos ang isang linggo. Dalhin ang Clinical Abstract,
Reseta at Index card.

CERTIFICATION OF HEALTH CARE PROFESSIONAL

I certify that the above information given in this form, including all attachments, are true and correct.

________________________________________ Date: June 2, 2020

Signature over Printed Name of Attending Health Care Professional