Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: Razon, Ella Joy Address: 136 Row 3 Unit 826 Baseco, Port Area, Manila Age/Sex: 7 yo/female Date Admitted: May 26, 2008 Admitting Diagnosis: Cerebral Palsy Anemia probably nutritional Protein energy malnutrition Physician–in-charge: Dr. Troncales/Salloman/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 1839743
PATIENT DISCHARGE SUMMARY This is a case of a 7 year-old female, from Baseco, Manila, who came in due to undocumented fever. HISTORY OF PRESENT ILLNESS 1 day prior to admission, patient had high grade fever, undocumented with associated anorexia and convulsion described as stiffening of the body. No associated cough, colds, hematuria, change in bowel movement noted. Persistence of symptoms prompted consult. . PAST MEDICAL HISTORY Patient was born to a 23 year old G2P2 mother, full term, via NSD at home. Mother had frequent cough and colds during pregnancy and took only paracetamol. There was no fetomaternal complications. Patient was breastfed for 1 year. Immunizations: (+) BCG at birth, (+) DPT x 3 doses, (+) Hep B x 3 doses, OPV x 3 doses, Measles vaccine x 1 dose No previous hospitalizations. Developmental history At par with age until 3 years old then noted deterioration until present. FAMILY HISTORY The patient’s mother denies any family history of asthma, diabetes mellitus, cardiac disease or respiratory diseases. PERSONAL AND SOCIAL HISTORY: Patient lives with parents and siblings in a crowded neighborhood at Baseco, Manila. Patient is fed only with milk since she would vomit when given solid food. Drinking water is boiled from NAWASA. Garbage is collectd daily. PHYSICAL EXAMINATION: General: awake, calm, not in cardiorespiratory distress Vital Signs: HR = 82 RR = 20 Temp = 36.70C Wt: 9 kg SHEENT: dry skin, anicteric sclera, pale palpebral conjunctiva, no cervical lymphadenopathy, no nosoaural discharge Chest/Lungs: SCE, no retractions, no crackles, (+) wheezes Cardiac: adynamic precordium, NRRR, no murmur Abdomen: flat, NABS, soft, no tenderness Extremities: full and equal pulses, no cyanosis, no edema ASSESSMENT: Cerebral palsy Anemia probably nutritional Energy protein malnutrition T/C CNS infection PLAN: For admission
Patient was admitted at the Pediatric ward 418 under the service of Drs. Troncales/Salloman/Manalo. Laboratories requested were CBC PC, BT, CXR APL, serum Na+ and K+. Patient’s diet was as tolerated. IVF: D50.3 NaCl 450cc to run at a rate of 75 µgtts/min. Medic`ations started were: Penicillin G 450,000 units every 6 hours SIVP (200,000 IU/kg/day) and Gentamycin 45 mg evry 24 hours SIVP (5 mkd). Vital signs with BP monitoring every hour. Seizures were watched out for. On the 1st hospital day, diet was as tolerated. IVF was revised to PNSS 1 L + 50 meqs KCl x 24 hours at a rate of 41 cc/hour. 15-L ECG was done. Patient was for repeat Na+ and K+ determination 24 hours after correction. Medications were continued. NGT was inserted and patient was started on osteorized feeding. Vitamin A 200,000 IU and Vitamin K 5g IV were given. Urine output was monitored. Vital signs were monitored every 2 hours.
On the 2nd hospital day, diet was maintained. IVF TF: PNSS 1 L + 50 meqs KCl to run for 24 hours. Medications were continued. Pediasure ½ glass TID was started. Blood culture was done. Vital signs were monitored every 4 hours. On the 3rd hospital day, osteorized feeding via NGT was continued. Paracetamol 100mg TIV was given for temperature > 37.8°C. IV medications were continued. Vital signs were continued every 4 hours. Summary of Laboratory Reports Hematology report: CBC with PC: WBC RBC HGB PLATELET NEUTROP LYMPHO MONO EOSINO Normal Values 8.0-38.0 X 109/L 4.6-6.6 X 1012/L 150-220 g/L 150-400 X 109/L 0.23-0.77 0.25-0.36 0.02-0.09 0.00-0.04 May 25 6.8 3.21 104 214 51 41