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JOSE R.

REYES MEMORIAL MEDICAL CENTER


Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF SURGERY

CLINICAL DATABASE
Hospital Number 2017052302
Date and Time of Admission 6/19/17 7:14 PM
Informant Patient
Admitting Service SURGERY-GSC

GENERAL DATA
Name: BUNCAIREN, JAMES RAS Age / Sex: 19/M Civil Status: SINGLE
Address: Gate 8 Parola, Tondo, Manila Occupation:
Chief Complaint: non-healing wound Birth Date: 7/24/1997 Religion: Catholic
CLINICAL HISTORY
3 MONTHS PTC, noted pimple on thigh, left. No medications taken. Interval history noted gradual enlargement and now associated with
erythema and thigh swelling. I & D was done however, patient failed instructions at home. Due to the persistence of symptoms, patient
seek consult at OPD and was advised for admission.
REVIEW OF SYSTEM
(-) Weight gain (-) Dental disease (-) Constipation (-) Breast mass
(-) Weight loss (-) Dysphagia (-) Change in bowel habit (-) Easy bruising
(-) Loss of appetite (-) Hematemesis (-) Urinary frequency (-) Bleeding tendencies
(-) Fatigue (-) Melena (-) Urinary hesitancy (-) Lymphadenopathy
(-) Night sweats (-) Hematochezia (-) Hematuria (-) Changes in behavior
(-) Headache (-) Polyuria (-) Depression
(-) Visual changes (-) Urethral discharge
(-) Diplopia
(-) Eye pain
(-) Dental disease
Past Medical History
(-) Hypertension
(-) Surgical operation
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Cardiac Disease
(-) Allergies
(-) Pulmonary Tuberculosis
Family Medical History
(-) Hypertension
(-) Cardiac Disease
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Allergies
(-) Pulmonary Tuberculosis
(-) Thyroid Disease
(-) Cancer
Personal and Social History
(-) Unremarkable
(+) Smoking 10 pack yrs
(+) Alcoholic beverage drinking
(-) Illicit drug use
(-) Others:
*Indicate (+) for positive finding, (-) for negative finding

PHYSICAL EXAMINATION
General Survey: active, alert, ambulatory, not in distress
Skin: Good skin turgor (-) pallor (-) jaundice
Head and Neck: anicteric sclerae, pale palpebral conjunctiva, no nasoaural discharge (-) deep tissue injury, (-) facial fractures
Chest and Lungs: Symmetric chest expansion, no lagging, no retractions, Clear breath sounds.
Cardiac: Adynamic Precordium, regular rate and rhythm, no murmur
Abdomen: flabby, normoactive bowel sounds, soft, nontender abdomen
Rectal Examination: not done
Extremities: No deformities: full equal pulses, no cyanosis, no edema, wound on left thigh
JRRMMC-F-SUR-IIC-27 July 1, 2016 Revision No.: 0 Page 1 of 2
JOSE R. REYES MEMORIAL MEDICAL CENTER
Rizal Avenue, Sta. Cruz, Manila
DEPARTMENT OF SURGERY

CLINICAL DATABASE

Neurologic Examination
GCS 15 (E4V5M6)
Cranial Nerves: Sensory Deep Tendon Reflexes Cerebellars
I. able to smell, differentiate scents on 100 100
both nostrils ( - ) Nystagmus
2+ 2+ ( - ) Dysmetria
II. pupils equally round, briskly reactive
100 100 ( -) Others
with light and accommodation
III. intact extraocular muscles Motor Meningeals
IV. intact extraocular muscles 5 /5 5/5
V. intact extraocular muscles ( -) Supple neck
VI. able to raise eyebrows, wrinkles 5/5 5/5 ( - ) Kernigs
forehead, blow checks, purse lips 2+ 2+ ( - ) Brudzinski
( - ) Others
VII. intact corneal reflex
VIII. able to hear rubbing fingers
IX. intact gag reflex, uvula in midline
X. intact gag reflex, uvula in midline
XI. able to shrug shoulder with or
without resistance
XII. able to protrude, retract tongue,
tongue in midline
ADMITTING IMPRESSION
ABSCESS, LEFT THIGH
MANAGEMENT PLAN
Admit to MSW
Secure Consent for admission and management
DAT with SAP
D5LR 1L x KVO
Ancillaries:
Attached to chart
Therapeutics:
Ampicillin-Sulbactam 1mg TIV q6
Clindamycin 300mg TIV q6
Omeprazole 40mg TIV OD
Tramadol 50mg/IV q8 PRN for pain
For Wound GSCS
Daily wound flusing with triple solution
Keep left leg elevated
Refer Accordingly

Prepared by:
Resident in Charge:
JI CARAS

JRRMMC-F-SUR-IIC-27 July 1, 2016 Revision No.: 0 Page 2 of 2