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REPUBLIC OF THE PHILIPPINES DEPARTMENT OF HEALTH Dr. JOSE R. REYES MEMORIAL MEDICAL CENTER
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila 1003

Department of Internal Medicine

Name: ALILING, Mercedita Villaruel Age/sex: 46/F DateofAdmission: Mar 7, 2014 Hospital no. 937925 Location: Payward I-4113-A

CLINICAL HISTORY

Chief Complaint: Epigastric pain History of Present Illness: The patient is a known case of Cholelithiasis, S/P Cholecystectomy with T-Tube insertion (Jan. 30,2014) and was discharged with T-tube. 12 days PTA (Feb. 23, 2014), the patient had accidental displacement of T-tube. There was no consult done and no medications taken. The next day, the patient had intermittent epigastric pain, aching, PS 5/10, non-radiating. Consult was done and patient was advised ERCP, hence this subsequent admission.

Review of Systems
GENERAL (-) colds (-) nausea INTEGUMENTARY (-) rashes HEAD AND NECK (-) headache (-) diplopia (-) aural discharge (-) postnasal drip RESPIRATORY (-) pleuritic chest pain CARDIOVASCULAR (-) nocturnal dyspnea (-) shortness of breath GENITOURINARY TRACT (-) dysuria (-) frequency (-) oliguria MUSCULOSKELETAL (-) myalgia (-) arthralgia (-) stiffness (-) swelling (-) limitation of motion (-) chills (-) vomiting (-) malaise (-) cough

(-) senile skin

(-) jaundice

(-) ulcer

(-) dizziness (-) photophobia (-) tinnitus (-) epistaxis

(-) head injuries (-) orbital pain (-) vertigo (-) hoarseness

(-) syncope (-) hearing loss (-) change in smell (-) sore throat

(-) blurred vision (-) ear pain (-) nasal obstruction (-) dysgeusia

(-) hemoptysis

(-) occasional cough

(-) easy fatigability (-) paroxysmal

(-) platypnea

(-) trepopnea

(-) pyuria (-) urgency

(-) hematuria (-) hesitancy

(-) lithuria (-) dribbling

(-) incontinence (-) polyuria

NEUROLOGIC (-) seizures ENDOCRINE (-) goiter

(-)memory loss

(-) tremors

(-) cold intolerance

(-) heat intolerance

(-) polyuria

(-) polydipsia

REPUBLIC OF THE PHILIPPINES DEPARTMENT OF HEALTH Dr. JOSE R. REYES MEMORIAL MEDICAL CENTER
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila 1003

Department of Internal Medicine

(-) polyphagia HEMATOLOGIC ( -) easy bruisability (-) abnormal growth

(- ) easy fatigability

(-) bleeding

Past Medical History (+) Cholecystectomy with T-tube insertion (Jan 30, 2014) Family Medical History (-)HPN (-) Asthma (-) PTB Personal and Social History
Patient is non-smoker, previous alcoholic beverage drinker and denies illicit drug used

Physical Examination
General Survey BP Skin and Integumentary HEENT Chest and Lungs Cardiovascular Abdomen Extremities Digital rectal exam GCS 15, conscious, coherent, ambulatory, not in distress HR RR T no pallor, no cyanosis, no rashes, no lesions, good skin turgor, no jaundice icteric sclerae; pink palpebral conjunctivae; no cervical lymphadenopathies, no TPC Symmetrical chest expansion, No retractions, clear breath sounds th Adynamic precordium; PMI at 5 ICS L MCL; normal rate regular rhythm, no murmurs Soft. Flabby, epigastric tenderness, normoactive bowel sounds, no mass palpated Full and equal pulses, no bipedal edema, no cyanosis No anal skin tag, tight sphincteric tone, no mass palpated, prostate not enlarged, empty rectal vault, no stool nor blood on examining finger

Neurologic Examination Mental Status Exam Sensorium Cranial Nerves I II III, IV, VI V1, V2, V3 VII VIII IX, X XI XII Motor Examination GCS 15 Normal NA 2-3mm equally and briskly reactive to light Full and equal EOM (+) corneal reflex; good masseter tone No facial asymmetry; N/A (+) gag reflex Can shrug shoulder Tongue in midline RUE 5 /5 LUE 5/5 RLE 5 /5 LLE 5 /5 Pronator drift N/A

Cerebellar Examination

REPUBLIC OF THE PHILIPPINES DEPARTMENT OF HEALTH Dr. JOSE R. REYES MEMORIAL MEDICAL CENTER
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila 1003

Department of Internal Medicine

(-) Babinski Reflex

Muscle Stretch Reflexes

Sensory Examination Meningeal Examination

Sensory deficit, Rombergs Test (-) Kernigs Test, Brudzinskys Test (-)

Present Working Impression Date March 7, 2014 Diagnosis Choledocholelithiasis S/P Cholecystectomy with T-Tube insertion (Jan 30, 2014) T-tube removal (2/27/14)