MANILA DOCTORS HOSPITAL

MEDICAL ABSTRACT

PATENT: FERNANDO, LARRY RAYO AGE GE

MPLE
Oste Atmitted ate inC
DrAttending
Roben Physician
m o1ar2021

Chief Complaint Fatula dn-Ane

Admiting Diagnosa Cischarge blagtois
Complex Anal P
Comple A
Reasons for Admsslon: For SURGICAL MANAGEMENT

7 montns PTA Patient let a mass on the Rbtocks wth associated pain (PS 7/9) on straning Patient aia soes set uns s
mass Patent dened lever, hematochezia, melena, anoreia, no consut was done at ths time
6monthts PTA Patient sought consut in Amsterdam due to the persistence of pustular drainage He was dagnaset wet
gven and patent Was advsed sugical management
tn the interim, pustular dranage was stil noted but not draining with pus all the time

Zm Apatient
bense arrived in the PH and consuted with AP. MRI showed fstutain-ana and protatomeay F
admission
Pertinent Past Medical History:
(-) HTN, DM, Aerg
SP Open Cholecystectomy (2019, Manila) SIP Tendon Cyst Excision (2017, MDH)
Rsson for the Request for Copy of Medical Abstract (for still admitad patierts): NIA
GNHisTORY
)LMP 9 NA
Partinent Signs and Symptoms on Admission (tck aççlicatie res
Atered mental sensorum ODiarhea Hematemesis
D Dizziness NHem
DAbdoninal cramppain
NHem
DAnoreia D Dysphagia
nitat
J Bieeding gums ODyspnea
Body weakness ODysura
unng ison DEpiataxis G e ngemit ecema
Dchest tdiscomfort UFever yega
UFrequency of urination dCnheerea
nConstipation
|Cough Headache Pain

Refered trom other healtth care insUtutlon (HCI) NO YES. Scecy Feasu
General Survey AAwake and Alert DAterec Serscr°
BP: 120M8O HR 61
Vital Signs Height (cm): 172 Weght (g): 5ã
Essentlally normal DAremal pupl reacter
HEENT Diceric sclera O Pale counctvae

DEssentially nornal wmmeacres:

exparscr
CHESTAUNGS DLump/s over breas/s Ras cracs es-onc

O Others

age