alvarez 48 by dredwardmark


									OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics NAME: ALVAREZ, ABEGAIL CYRA Hospital Number: 1494130 AGE/SEX: 5 months/ Female ADDRESS: Barangay 649, Baseco Port Area, Manila DATEOF ADMISSION: May 24, 2008 ADMITTING DIAGNOSIS: Acute gastroenteritis with moderate dehydration PHYSICIANS-IN-CHARGE: Dr. Troncales/Dr. Salloman/Dr. Manalo CLERKS-IN-CHARGE: Cuvin/Erum/Fernando/Figueras/Fuentes Florentino/Kalalo/Lingao/Liwag/Lopez PATIENT DISCHARGE SUMMARY Informant: mother % Reliability: 90% Chief Complaint: watery stool This is a case of a 5-month-old female who was brought in due to passage of watery stool. HISTORY OF PRESENT ILLNESS: 4 days prior to admission, the patient had passage of watery stools, yellowish in color, non-mucoid, non-bloody. There was no vomiting, fever, cough, or colds. No consult was done. No medications given 1 day prior to admission, the patient had persistence of the above symptoms which prompted consult at the pediatrics OPD and fecalysis was done which was unremarkable. The patient was given protexin and glucolyte. Few hours prior to admission, the patient still has persistence of the above symptoms thus subsequent admission. PAST MEDICAL HISTORY: Pre-natal: the patient’s had no maternal illnesses during pregnancy. The patient’s mother also had 2 prenatal check-ups and took vitamin A and FeSO4. Birth: born full term to a 21-year-old, G5P4 (4-0-1-4) mother via NSD at home by a midwife. Post-natal: No cardiorespiratory distress. No jaundice. No previous illnesses. No feto-maternal complications. Feeding: She was breastfed up to 1 month. At 1 to 5 months she was fed with Bonna 1:2 and was shifted to Nestogen 1:1 3 days ago. Growth and Development: Patient is at par with age. Previous hospitalizations: none Childhood illnesses: no asthma, no allergies to food and drugs Immunization: (+) BCG, 1 dose. (-) DPT, 2 doses (+) OPV 1 dose FAMILY HISTORY: (+) asthma (-) cardiovascular disease (-) DM (-) renal disease (-) cancer (-) allergies (-) PTB PERSONAL AND SOCIAL HISTORY: The patient active and is given multivitamins (Tiki-tiki) once a day. PHYSICAL EXAMINATION: General: carried by mother, awake, irritable and not cardiorespiratory distress. Vital Signs: HR = 150 RR = 40 cpm Temp = 37.70 C Wt = 5 Kg

Skin: no jaundice, no skin tenting HEENT: Head: no scars, no tenderness Eyes: Anicteric sclera, pink palpebral conjunctiva, (+) sunken eyeballs. Ears: no discharge Nose: no alar flaring, no nasal discharge Mouth/Throat: no tonsillopharyngeal congestion, moist lips and mucus membrane, no Neck: (-) CLAD Chest/Lungs: Symmetric chest expansion, (+) intercostals & subcostal retractions,
bronchovesicular breath sounds Heart: adynamic precordium, normal rate and regular rhythm, no murmurs Abdomen: globular, normoactive bowel sounds, soft, no palpable mass Extremities: grossly normal, no edema, no cyanosis, full and equal pulses ASSESSMENT: Acute gastroenteritis with moderate dehydration PLAN: for admission The patient was advised for milk feeding as tolerated by AL 110. D5IMB 600cc was given to run at 25 cc/hr. The patient was started on ampicillin 166mg TIV every 8 hours (100mkd), immunosine 0.6 ml bid PO, vitamin A 100,000 IU single dose PO, and protexin sachet bid. The patient was requested for CBC with PC, urinalysis, and fecalysis. Input and output was monitored. Vital signs were monitored every 2 hours. COURSE IN THE WARDS: On the 1st hospital day, diet was maintained. IVF was maintained. Medications were continued. Input and output was monitored. Vital signs were monitored every 2 hours. On the 2nd hospital day, diet was maintained. IV fluid that followed was D5IMB 500cc was given to run at 25 cc/hr. CBC and PC and urinalysis was followed up. Medications were continued. All losses were replaced. Input and output was monitored. Vital signs were monitored every 2 hours. On the 3rd hospital day, diet was maintained. IVF to follow was D5 IMB x 24 hours to run at a rate of 20-21 ųtts/min. Medications were continued. Dose of ampicillin was increased to 250 mg q 8 SIVP. Frequency and consistency of stools were monitored. Losses were replaced with PNSS. Vital signs were monitored every 4 hours. On the 4th hospital day, milk feeding with Al 110 was continued with strict aspiration precaution. IVF was maintained. IV medications were continued. On the 5th hospital day, patient was allowed to go home. Take home medications were Proziznc drops, 1 mL OD for 2 weeks. Mother was advised to continue AL 110 for 2 weeks. For follow up at the Pedia-OPD after 5 days. SUMMARY OF LABORATORY EXAMINATIONS Fecalysis (5/24) Color: yellow Consistency: semi-formed Pus: 0-1 RBC: 0-2 Ova/parasite: none Complete Blood Cell Count with Platelet Count (5/24) WBC: 4.1 Neutrophils: 45 RBC: 2.98 HGB: 81 HCT: 23.1 Platelet: 239 ulcerations

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