Clerkship Abdominal Thorax Surgery Ward Patient list
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An listing patient information and documentation, which describes a clinical info from in and out. Diagnosis, management, And prognosis.
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Clerkship Abdominal Thorax Surgery Ward Patient list
- 1. Patient List CHA-KSFH-G3 27/12/21-04/3/22 Demonstrated Sim Ti MD 6th. UP Cambodia 🇰🇭
- 2. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 4/13 Yim Dalisa 16F 958433 Appendicitis Bloomberg Rovsing Fever 3days Écho Normal BWC 21 Neutrophil 82 28/12/21 Appendecto my Catarrhal PIV Antibiotics Antalgique Plaie propre 4/16 Sem Sambath 46M 958640 Cholecystiti s Murphy + Tenderness Fever VB 52mm Paroi 8mm Calcul 6mm PIV Antibiotics Antalgic 11/33 Sen Soy 55M 955614 Tumeur Colon Droit T4 RIF tenderness Fever Weight loss US Appendicitis WBC 12 Neutrophil130 K 3 CRP 119 23/12/21 Right Hemicolect omy Anastomose NGT BTF 2 Antibiotics Antalgique Plaie Propre 17/47 San Bunthon 50M 952455 Peritonitis Général Abdo distention Rigidity Fever -Gas Épaisse paroi VB( Suspect cholecystite Perforate) Liquid Moyenne Albumin 27 Oesinophile 9 Hg 11 8/12/21 Laparotomy Lavage Drainage PIV Antalgique Antibiotics Plaie propre
- 3. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 24/61 28/12/21 Plaie Abdomimal Abdo Rigidity 24/64 Tang 1im 91F 958235 Calcul vesicule Bilaire Murphy+ Post Prandial Deux Calcul 6mm CRP 13 WBC 11 PIV Antibiotics Antalgic 37/89 Mon Sopheak 35M 955059 Tumeur Tête Pancréas Courversier+ (Enlarged Nontendernes VB, Painless Jaundice) Mass head Pancreas +Pancreatiti s WBC 12-15 Lipase 133-122 CPK 194 T-Billirubin 13 Glu 239 ALP401 4/1/22 (DPC) Whipple procedure NGT 10cc Drain 50cc+ 50cc Urine 300ml Liquide kystes 60x128mm 40/92 Soam Phae 61F 957384 Tumeur abdominale Abdo Distention Mass Supra pubic +US: Mass kystique suprapelvienne 177+160+190m m PIV Antibiotics Antalgic Globe vésicale non palpable
- 4. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 40/94 Ek Soaphorn 49F 954672 Calcule Cholédoque Anémie Itére Murphy + Fever Dilatation cholédoque 19mm Calcul à la cholédoque 14mm Na 128 Platelet 744 T-Billirubin 4.2 GGT 532 ALP 883 Hg 10.9 22/12/21 Cholecyste ctomy PIV Antalgique Antibiotic Plaie propre 41/95 SronSopheab 42F 942057 Lithiase vésiculaire RUP pain Post Prandial Calcul VB non Obstrutif WBC 10.30 27/12/21 Endoscopic cholecystec tomy PIV Antibiotics Antalgique Plaie propre 42/108 Nhel Sreyny 28F 958443 Appendicitis Grosses RLQ tenderness Rovsing + Fever # US : Appendicitis #US : Avortement 20SA #De’ Echo closione 10*5.2cm 11cm #FID 3cm, Retro 6cm WBC 21.98 Neutrophils 90 7/1/22 WBC 15 8/1/22 Ca 7.6 Albumin 21 WBC 20.22 Hg 9 Neutrophil 90 28/12/21 Appendectomy +peritonitis local 7/1/22 LAPAROTOMY lavages abces closione et bowel adhésion PIV Leflox,Ceftri,mét ro Antalgique Cytotic Oxytocine ICU Fetal lost WBC 13.48 Hg 8.3 Platelets 90 42/104 Angiocholit e Murphy’ Itere Fever WBC 20 CRP 16 PIV Antibiotics Antalgic
- 5. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 42/108 Emphysèm e cutané Crapitant subcutaneous Pénétrâtes injurie Subcutaneou s emphysema WBC 9 PIV Antibiotics Antalgique Plaie propre 43/116 Theng Mek 68F 957963 Calcule Cholédoque Murphy + Fever Anémie Itérer Hydrocholecyst Cholédoque 19mm Calcul ou bas du cholédoque 12mm Na 131 Hg 8”8 CRP168 GGT 484-122 ALP 547 Urine - 30/12/21 Cholecystecto my Extraction calcul Kerh Drain PIV Antalgique Antibiotics 31Kerh:400ml 2Kerh 700ml 4Kerh 400ml 5Kerh 300ml 6kerh 400ml 7kerh 600ml 8kerh 250ml 3/9 Kong Phat 61M 958798 Cholecystit e Lithiasis Murphy + Fever Tenderness Calcul Multiple 19mm , paroi thickening 5/1/22 BWC 13,45 GGT 228 7/1/22 WBC 9 3/1/22 Endoscopic Cholecyste ctomy PIV Antalgique Antibiotics Plaie propre Hypertensio n 32/82 Chorn Si 26 M 958016 Rupture du Foie et rate Abdo. Regidity +Distension post Traumatisme Foie: Contusion hypodensite IV, V, VI (GIII) Rate: Rupture Corticale G(2) Hemoperiton WBC 21 Neutrophil 88 28/12/21 Laparotomy exploration PIV Antibiotics Antalgic Plaie propre
- 6. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 2/6 Rous Ngon 60F 958899 Lithiasis vesiculaire Itere Murphy + Fever Boas’s + Calcul 5mm Paroi fine CRP 16 Eosinophil 9 31/12/21 Cholecyste ctomy endoscopy PIV Antibiotics Antalgic Urine 700ml NGT 100cc Drain 80cc 24/62 Tep Man 70F 959809 Cholecystit e alithiasique Murphy+ Ilieus Douleurs Post Prandial Épaisses de la paroi 10mm vesiculaire 5/1/22 WBC 21 Hg 7. 6 Neutrophil 92 7/1/22 BWC 15 PIV Antibiotics Antalgic FOGD Colostomy 2/8 Mai Meng 50M 959903 Appendicitis Bloomberg Rov sing Fever Appendicitis hypertrophi c 12mm WBC 9.5 Neutrophil 80 TP 65 2/1/22 Appendicitis phlegnoreous PIV Antibiotics Antalgic Plaie propre 16/40 Nov Seam 98 F 959858 Abcès du foie RUP pain Fever Malaise Abces du foie 45*39**45mm Paroi polylobe de lobe hépatique Gly 380 Albumin 26 CRP 48 Hg 9 WBC 11 Neutrophil 88 2/1/22 Percutaneo us abscess Drainage PIV Antibiotics Antalgic ICU
- 7. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 2/6 Hean Net 20F 959893 Tumeur Mediastinal e Caugh+++ Dyspnée Facial plethora 16x23 mm Nodule sous capsulaire au S5 du foie. WBC 21 PIV Antibiotics Antalgique Antitussive Salmeterol Consult radio interventionelle et Biopsy SVenacava Syn. 4/14 Pet Sok 65M 969847 Ancienne Colostomy Sac colostomy a gouche Épaisses irrigulaire de la paroi vasicale 2/12/20Biopsy Adenocarcinoma G2T3 PIV Antibiotic Antalgique Colon transverses 7mm sessile polyps 17/41 Heng chantha 41F 935530 Plummer Diseases (Goitre MultiNodulair e) Pulse 84( On Carbimazole) Goiter with palpable Muitlnodulaire. Nodule Tirad 4 et toxique 13/10/21 T3: 0.20 T4: 0.10 TSH: 100 7/1/21 T3T4TSH nornal 11/1 /22 Thyroidecto my total PIV Multi Antibiotics Levothyroxine 100 mcg Calcium Gluconate Program 30/74 Soam Narith 63M 958422 Peritonitis perforation Vésicule biliaires Murphy Rigidity Fever Distension Aerobilie Cholecystitis emphysema 82*100mm WBC 25 Hg 9.2 Na132K3.38 Lipase 634 Amylase 288 2/1/22 Laparotomy exploration lavargement PIV Antibiotics Antalgique 48hrHct 30 Gly 131 Ca: CRP
- 8. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 32/81 Min Soknang 28M 961527 Contusion Abdo/AVP RUQ pain Fracture clavicle Dt Contusion lobe droit hépatique WBC 20 Neutrophil 88 PIV Antalgique Antibiotics Hgram 6/19 Ben Neb 78F 961468 Kystes hydatide calcife rupture post Traumatisme RUP pain Fever Kyste Hydatide 16x12x19 Moyenne abandon Hg 9.8 Neutrophil 83 PIV Bed rest Antibiotics Antalgic Hypertension 42/106 Ul Thea 41F 961649 Hemobilia Murphy + Itere Boas Melana Anémie Dilate wirsung 10mm Choledoque 9mm 3 calculs Hg 8 PIV Antibiotics Antalgic FOGD Youy Yet 21M 946344 WBC 23 Hg 7 Neutrophil 89 Glu 326
- 9. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation ICU Prom Sun 63M 961641 Pneumothorax Droite Dyspnée Chest Asymmetry Right Pneumothorax with mild pleural effusion WBC 15 Hg 10 Neutrophil 88 8/1/22 Drainage Thoraxic PIV Antibiotics Antalgique Canule O2 Drainage SpO2: Control X-ray 41/102 An chrel 42M 958374 Ancienne Colostomy Stomy Anapath: Adenocarcino ma mucosa type defuse de colon 14/2/22 Anastomose PIV Antibiotics Antalgic Consult anesthesia program 14/2/21 42/104 IN Saron 41F 622777 Ancienne Colostomy Stomy WBC 14 PIV Antibiotics Antalgic 21/49 Chhit Virak 17M 962975 Acute Appendicitis Bloomberg + Rosing+ Appendicitis 8.5mm WBC 20.70 Neutrophil 81 CRP 16.4 12/1/22 Appendectomy PIV Antibiotics Antalgique
- 10. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 3/12 Somrith Sarern 81F 962856 Calcul Choledoque Murphy + Fver Itere Charcut Calcul Choledoque obstruction 21mm WBC 16.74 Hg 9.7 PIV Antibiotics Antalgique 2 PPIs FOGD: Gastric Ulcer Forrest III ICU Hem Ri 38M 962823 Peritonitis par pancreatitis et Appendicitis rédactionnelle Abdo Rigidity Fever Distension Appendicitis 9mm Trouble Ion Gly 519 CRP133 12/1/22 Laparotomy Lavagement Appendectomy PIV Antibiotics Antalgique NGT 4 Drainage 26/65 Seng Penghouy 67F 962178 Tumeur Rectum Anémie Hematochezia Mass colon G Tumeur colon G Hg 9.2 Platelets 67 Oesinophil 9 17/1/22 Colostomy PIV Antibiotics Antalgique 30/75 Su Khorn 61M 963063 Hydrocholestit e Covoisier sign Fever Canal Choledoque 16mm Masse pancreatic 39x44mm Lipase 246 Tbillirubin 23.8 ALP 1037 WBC 13.20 PiV Antibiotics Antalgic
- 11. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 1/1 Kim Sern 49M Fracture du côte (flail chest) Douleur au movement thoraxic Flail chest fracture au 2- 7th Neutrophil 80 TP 69 PIV Antibiotics Antalgic 2/6 Li sol 59M 963192 Tumor du foie Distension abdo. Masse hypoechogene lobe droit Boue biliaire WBC 21.52 Hg 11.5 Neutrophil 84 GGT 88 Albumin 23 16/1/22 LAPAROTOM Y PIV Antibiotic Antalgic Bilan Hépatique CEA AFT 43/115 Pok Penh 76M 370402 Cholecystite Murphy + Fever Boas + Cholecystite calcul 9mm WBC 15.76 Hg11.1 Neutrophil 85 PIV Antibiotics Antalgic 43/116 Lam Sea 64M 895988 Abcès le grand epiploon para ombilical Sub Occlusion Fever Abces du epiploon 39x34mm Gly 187 12/1/22 Radio interventionelle injection drain PIV Antibiotics Antalgic
- 12. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 23/59 Kan Ravy 32M 963143 Pancreatitis Abdominal Distension Bloomberg Appendicitis witg lame liquide espace de Morrisons Low Platelets et Tp 12/1/22 Peritonitis appendicitis PIV Antibiotics Antalgic 4/14 Seab Mon 43M 500495 Appendicitis Bloomberg Fever Rovsing Appendicx 5.3mm Neutrophil 38 EOSINOPHIL 6 Tp40 13/1/22 Peritonitis appendiculare PIV Antibiotic Antalgic 31/79 Sor San 68F 953455 Adénocarcino me du Rectum Tenesmus Mass abdo Stéatose hépatique modéré Gly 166 HbA1C 7.4 GGT 123 19/1/22 Colostomy PIV Antibiotics Antalgic Med B Chun Khorn 44M 964014 Tumeur colon Droite Tenesmus Masse abdo Anémie Hepatopathie chronique Hg 7 Hepatitis B 21/122 Colostomy PIV Antibiotics Antalgic Consultez à Med B
- 13. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation ICU Keo Chaignoun 81M 964539 Pneumoperiton Regidity abdo Hematochezia 2 fois Pneumoperiton WBC 20 17/1/22 Pneumoperiton par perforation diverticule PIV Antibiotics Antalgic 3/10 MoK yimlas 57F 964581 Kyste Hépatique Mass RUQ Cholique abdo Mass hépatique 59*52Mm Mass pelvienne 120x99mm LDH 698 Neutrophil 85 24/1/22 Tumeur Retroperitoneal Métastases du foie PIV Antibiotic Antalgic Stomy 23/59 Ouch E 23F 966037 Se Occlussif Abdo distention Gas- Trouble Ion GGT 308 ALP 311 WBC 31 Hg 7.9 CRP 166 PIV Antibiotics Antalgic 30/76 Dim Doung 56M 966139 Péritonite appendicular Rigidity RLQ Bloomberg Rovsing Fever Appendicitis Neutrophil 90 Albumin 22 Amylase 239 22/1/21 LAPAROTOM Y médian PIV Antibiotics Antalgic
- 14. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 1/1 D’or Pherk 51M 966121 Thoracic trauma Gly140 Neutrophil 90 PIV Antibiotics Antalgic 1/3 Pery Pov 81M M 966205 Abcès appendiculaire Bloomberg Rovsing Fever Appendicitis 10mm WBC 17 Hg9. 6 22/1/22 Appendectomy PIV Antibiotic Antalgic Eng TangChhor 81M Absces Splénique Abdo tenderness Distention 26/1/22 Ascending colon diverticulosis PIV Antibiotics Antalgic Meng Leang 65M Occlusion post.op Abdi Distension Sténosage du colon transverse dt 11mm épais 55mm PIV Antibiotics Antalgic
- 15. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 17/47 Net Mom 55F 966274 Sd Occlusion post Colostomy Gas- Stool- Abdo Distension Créatinine 101 PIV Antibiotics Antalgic 17/43 Pok Penh 76M 370402 Cholecystite Murphy Fver Cholecystite 9mm calcul WBC 13 Hg 8.7 Neutrophil 80 19/1/22 Cholecystecto my PIV Antibiotic Antalgic 31/80 Un Sovan 71M 940311 Ancien Colostomie posttraumatic Colostomy PIV Antibiotics Antalgic 31/79 Sor San 68F 953455 Adenocarcino ma du rectum Mass supra pelvienne Normal Normal 19/1/22 Resection anterior PIV Antibiotics Antalgic
- 16. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 2/7 Tan Rom 42M 966285 Abcès appendiculare Bloomberg Rovsing Fver RLI regidity Abces appendix 22x13mm hypertrophic 11mm WBC 12 CRP 333.5 28/1/22 WBC 15 23/1/22 Péritonite général PIV Antibiotics Antalgic Drain 9/26 Bol SreyNeang 20F 970669 Sd Occlusion Gas- stool- Abdo Distension Vomissements PIV Antibiotic Antalgic 27/67 Ea Lyhoung 50F 965402 Fistule anale Wound perianal Sedated fluid Abcès a la couche a fesse gouche 61x22mm Abces coccyx 12x52mm WBC 12 Hg9 22/1/22 Debritement larvement culture PIV Antibiotics Antalgic Antibiogram -Genta -Amikacine -Meropeneme 17/41 Ang Ery 66M 967880 Kyste tete de la epidydymite Dt Douleur FIG Petit kyste a la tete de l'épidémie Dt Normal PIV Antibiotics Antalgic
- 17. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 9/26 Seang Sitha 38F 965097 Cholelithiasis RUP pain Post Prandial Murphy Lithiase vesiculaire WBC 11.08 25/1/22 Cholecystecto my PIV Antibiotics Antalgic 10/30 Cherng Sadern 32F Plummer Diseases Goiter MultiNodulaire Nodular Goitre multiple tirads 2 WBC11.61 TSHT3T4 normal Ca 11 CRP 11. 2 27/1/22 Thyroidectomy PIV Antibiotic Antalgic Levothyroxine Ca2* Gluconate 24/61 Ret Vanny16F 966288 Peritonitis General Abdo regidity Distension Liquide cloisone Wbc 18 Hg 9.8 Neutrophil 81 23/1/22 LAPAROTOM Y lavages PIV Antibiotics Antalgic 27/67 Keo ChaiGnoun 81M 964538 Peritonitis Perforation Organ creux Distension Regidity Gas- Suspension dun gas prehepatique WBC 18.44 Neutrophil 88 17/1/22 Colostomy LAPAROTOM Y lavages PIV Antibiotics Antalgic Stomy
- 18. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation Kloch savern 59M Hemothorax Dysnea Post traumatic Chest pain Contusion pulmonary Emphysema subcutaneous Hemothorax 1/2/21 Chest drainage PIV Antibiotics Antalgic Tuy Yan 58M 968200 Pneumothorax dt Chest asymmetry Dysnea Pneumothorax Dt Hydrocholecyst e (DAP: 59mm) 30/1/22 Chest drain PIV Antibiotic Antalgic Nich 23F 970470 Traumatisme abdo Bruise abdo Douleur RUQ Contusion hépatique lame liquid perirenal Dt Hg11.9 K3 PIV Antibiotics Antalgic Pulse 86 TA100/60 D’y Samon 63F 969706 Goitre Toxique Mass on the neck Tirad 4, Goitre nodules T3: 3,96 T4: 1.90 TSH< 0.01 ALAT 463 ASAT 666 WBC 13.98 PIV Antibiotics Antalgic EchoCardio: AFib
- 19. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation Phark Chhit 27M 970459 Effusion pericardique Dysnea intense Progressiveme nt Pleuretic Chest pain Pleurésie Gouche de grosse abandon Mass compressive WBC 16.04 PT 55 6/2/22 Puncture drainage PIV Antibiotics Antalgic SpO2: 99 sous canule O2 5ml 17/44 Chey Pheakdey 34M 970532 Abces appendicitis Bloomberg Rovsing Fever Abces appendix 8mm WBC 14.13 Neutrophil 86 06/02/22 Appendectomy peritonitis locale PIV Antibiotic Antalgic 31/80 Oun Sovan 71M 940311 Ancienne Colostomy Stomy Colposcopie :Colon ulcer WBC 11.01 Hg11.9 01/02/22 Rétablissemen t digestif PIV Antibiotics Antalgic 23/57 Vat Chanthon 46F 968858 Sd Occlusion Gas- Stool- Abdo Distension Nodule hépatiques Dilatation des anse grelique 38mm Hg11.3 CRP 45.2 6/2/22 Adhésiolyse structuroplasty PIV Antibiotics Antalgic
- 20. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 9/27 Nhem Chany 41F 969168 Fistule anale Ulcer perianal Palpable lesion Eosinophil 12 Gly 194 CRP 10.7 6/02/22 Fistulostomy PIV Antibiotics Antalgic 21/52 Houn Lihour 18M 970479 Peritonitis général chez Colostomy Abdo regidity Abdo Distension Colostomy Lame liquide faible abandon WBC 14.14 06/02/22 Peritonitis perforation grêles PIV Antibiotic Antalgic 31/78 Hot Hel 83F 969093 Lithiase vesiculaire Douleurs Post Prandial Cacul vesiculaire 15mm WBC 11.19 Neutrophil 84 Gly 180 PIV Antibiotics Antalgic Hyoscine 2A Amlo 5mg 10/30 Ses Chanthon 57M 970585 Liver abscess Douleur RUQ Fever Ictère CT abces du foie 48x42x41mm Hg 12.3 ALAT 126 CRP 162.1 06/02/22 LAPAROTOM Y incision drainage S VII PIV Antibiotics Antalgic
- 21. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 17/41 ANG Ery 66M 967860 Hernie inguinale gouche Mass inguinale reducible Petit kyste de la têtes epididyme Normal 01/02/22 Hernia Inguinal gouche PIV Antibiotics Antalgic 4/14 Tim Rin 78F 968988 Traumatisme thoraxic G Dyspnée Plaie thoraxic Lame liquide intra Peritoneal et pleural bilateral Eosinophil 19 Hg 10.1 Na 125 PIV Antibiotic Antalgic 43/113 Phum Meas 41M 967741 Sd de cholestase Covoisier + Ictère Fever Douleurs RUQ Hepatomegalie Dilatation voie intrahepatique WBC 16.97 Neutrophil 82 GGT 630 Bilirubin 18 2/02/22 Tumeur calcul Choledoque T4NxM0 PIV Antibiotics Antalgic Kerh 1000ml 17/43 Mony ChanMonen22 M 970633 Bowel Ostruction Gas- stool- Abdo Distension Lame liquide pleural dt ASP: Hydroareique WBC 19.01 PT 48 PIV Antibiotics Antalgic
- 22. Patient’s ID Diagnosis Clinical sign Radiology Lab test Peri-post Operation Manageme nt post Op. Revaluation 23/58 Thy Soa 68M 920188 Pancreatic chronique Ictère Douleurs radiation a dos Vomissements WBC 17.95 Neutrophil 95 Bilirubin 7 ALAT 398 Asat 239 CRP 25.3 PIV Antibiotics Antalgic 12D Ern Nai sim 30F. 620249 Sd subOcclusion Gas- stool- Abdo Distension Vomissements PIV Antibiotic Antalgic Sonde naso PIV Antibiotics Antalgic PIV Antibiotics Antalgic