OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila
Patient’s Name: Fernandez, Ruel Address: 1658 Kahilo St. Pndacan, Manila Age/Sex: 4 mo/M Date Admitted: May 30, 2008 Admitting Diagnosis: Anemia, Etiology to be determined; R/O G6PD Deficiency Physician–in-charge: Dr. Troncales/Salloman/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No.
Clinical Abstract This is a case of a 4 month-old male born full-term to a 28y/o G6P6 (6-0-0-6) via NSD assisted by a midwife who came in due to pallor. HISTORY OF PRESENT ILLNESS Two weeks PTA, mother noted that the patient had bipedal grade I edema with associated decrease in urine output without hematuria. There was no associated cough, colds, fever, seizure, or poor feeding. After 1 day, edema disappeared and urine output returned to normal. Patient was apparently well, until one day PTA, patient was noted to be irritable with incessant crying. Three hours PTA, patient was brought at the local health center for his scheduled HepB vaccination. PAST MEDICAL HISTORY Patient was born to a 28 yo G1P1 mother via NSD, with no fetomaternal complications. Immunizations: (+) BCG x 2 doses, (+) DPT x 2 doses, (+) Hep B x 2 doses No previous hospitalizations. FAMILY HISTORY The patient’s mother denies any family history of asthma, diabetes mellitus, cardiac disease or respiratory diseases. PERSONAL AND SOCIAL HISTORY: Patient is a cheerful child. Development at par with age. Patient lives with in a congested household with 7 other relatives. Patient’s mother has had cough for a month. The house has 2 windows, with 1 pour-flushed bathroom. Drinking water is boiled from NAWASA. Garbage is collected daily. PHYSICAL EXAMINATION: General: Asleep, comfortable, in mild respiratory distress Vital Signs: HR = 120s RR = 66 Temp = 37.90C Wt: 11.3 kg Anthropometrics: Weight = 4.3kg Length= 51cm HC= 37cm AC= 33cm CC=37cm SHEENT: good skin turgor, anterior fontanel not depressed, anicteric sclera, pink palpebral conjunctiva, no no cervical lymphadenopathy, nasoaural discharge Chest/Lungs: SCE, (+) chest indrawing, (+) subcostal retractions (+) crackles both all lung fields Cardiac: adynamic precordium, NRRR, no murmur Abdomen: globular, NABS, soft, no tenderness Extremities: grossly normal extremities, full pulses, no cyanosis, no edema ASSESSMENT: Pneumonia, Severe PLAN: For admission
Patient was admitted at the Pedia Ward Rm. 420 under the service of Drs. Troncales/Salloman/Manalo. Laboratories requested were CBC PC, CXR APL and Blood CS. Patient’s diet was anything tolerated with SAP but was placed on temporary NPO with HGT monitoring q12. IVF: D50.3 NaCl 500cc to run at a rate of 21-22µgtts/hour. May have O2 support via cannula at 2-3 lpm. Medications started were: Ampicillin 150 mg SIVP q8 (105 mkd) and Gentamycin 11mg q12 (5mkd). WOF: respiratory distress like increase in RR, cyanosis, deepening of retractions. On the 1st HD, patient was maintained on NPO. O2 support was given at 5-6 lpm. Residual IVF: D5IMB 500 cc to run at a rate of 23-24cc/hr. Ampicillin was increased to 250mg SIVP q8 174mkd. Other medications were continued. WOF: progression of respiratory distress. Patient was monitored VSq2.