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MANILA DOCTORS
HOSPITAL
MEDICAL ABSTRACT
PATIENT: FERNANDO, LARRY
Attending RAYO
Dr. Rober Physi clan:
D. Lim
CVS Ebsenlialy normal
DIregular Rhythm
D Other:
ABDOMEN Essentlally normal
OPalpable mass(es)
DOthers:
GU: (E) DEssentialy normal
Others: Dot dons
Essentially normal
D Edema /I Swelling
SKINIEXTREMITIES DRashes /Petechial
|Others:
NEURO EXAM Essentially normal
DAbnormal Reflex(es)
DOthers:
Dale Admitted:
09/12/2023
D Displecod apex beot
Mulled honri sounds
DAbdominal rigldity
OTynpana nltlc /Dul
D Blood stained
examining finger
DCubbing
D Decreased mobüty
OWeak Pulses
DAbnomal gait
O Poor altered memory
PATIENT ID:
2174441
AGE GENDER
56 MALE
Dale Dlscharged:
08/14/2023
DHeaves andlor thills
O Murnur
DAbdominal tenderness
D Uterine contraction
O Cervical dilatation
DCold clammy skin
D Pale nailbeds
OAbnormal position sense
O Poor muscie tonelstrength
CMIL STATUS
MARRIED
Date Transferred:
NF
D Pericardial buige
D Hrperecve bowel sounds
OAbnormal discharge
DCyanoss / motting
DPoor skin turgor
DAbnormal sensation
D
Poor coordination

DIGITAL RECTAL
DEssentially Normal DMass OPus
DEnlarge Prostale OHemorrhoids
Others: fstula on intenal opening Rbutocks
COURSE IN THE WARD (photocopy of laboratory lmaging rosults attached) Chock box if there aro additional shoot()s)
DATE DOcTOR'S ORDERAND ACTION
09/12/2023
Paenasseen and examined. Hislory and PE reviewed. Patient was admited under the service of Dr. Lim. Patient was
for mplated procedure September 13, 2023, Consent secured. Palient was duly monitored and refered
accordingly.
09/13/2023 Patient underwent contemplated procedure and was able to tolerate it well, Patient was duly
monitored and referred accordingly.
09/14/2023 Palient was seen and examined. Was deemed fit for discharge. Was given take home medications and and advised folow-up.
Palient was discharged stable and well
Surgical Procedure RVS Code (Attach photocopy of OR technique): Dato Performod:
Proclosigmoidoscopy, Anal Fistulotomy with Seton Placement Seplember 13, 2023
Histopath Result: To Follow
OUTCOME OF TREATMENT: CHECK ( ) APPROPRIATE BOX

DRECOVEREDMPROVED CCRITICAL ABSCONDED DHAMA DIED TRANSFERRED

CERTIFICATION OF ATTENDING HEALTHCARE PROFESSIONAL
ICERTIFY THAT THE ABOVE INFORMATION GIVEN IN THIS FORM, INCLUDING
ALLATTACHMENTS, ARE TRUE AND CORRECT:
DR. ROBERT D. LIM/DR./ON LE^FER
Signalure overUY
printed nemeo 09/21/2023

PRC:
Allending Healthcare Prolessional MANILA OOCTORS HOSPTAL Dale Signed
PTR: 0152850 MEDNCAL RECoRDS DEPARTMENT

HETH PEHORAPETECHI
MAGIO
PRINT NAE
JANDATEPIGNZOZL
CERTIFIED TRUE COPY
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03/01/2023