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Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila Patient’s Name: Tukan, Alrauf Age/Sex: 2/M Address: Bgy 649 Zone 68 Baseco Port Area, Manila Date Admitted: May 28, 2008 Admitting Diagnosis: Dengue Hemorrhagic fever II Physicians–in-charge: Dr. Troncales/Dr. Salloman/Dr. Manalo Clerks-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez PATIENT DISCHARGE SUMMARY Hospital No. 1841276 This is a case of a 2 year old male who was brought in due to fever. HISTORY OF PRESENT ILLNESS The patient was apparently well until… 4 days PTA, patient had high grade fever of 40 °C with associated mucosal watery nasal and occasional cough. Patient was give n Paracetamol (10 mkd) and Amoxicillin (76 mkd). 2 days PTA, patient still with fever with mucoid nasal discharge and episodes of vomiting. Patient also had episodes of epiga stric pain and was given Paracetamol (10 mkd) and Patient was then brought to OMMC for consult and was prescribed with A,oxicillin (50 mkd). 1 day PTA, patient still had fever associated with cough and watery nasal discharge. Patient had macular non pruritic rash erythematous rash with decreased appetite and vomiting (2 episodes) with epigastric pain. No cyanosis, no seizure, (+) dysuria. Few hours PTA, the persistence of epigastric pain and vomiting with fever. Patient was then brought to a private clinic and CBC with PC result showed 104 platelet count. Thus patient was then brought to OMMC for consult and was subsequently admitted. PAST MEDICAL HISTORY 1. BIRHT HISTORY Patient was born to a 19 year old G1P1 (1001) mother via NSD at LHC without any complications. Mother claims to have had regular prenatal check up and denies illness during the course of pregnancy. 2. DEVELOPMENTAL Can walk, run, jump upstairs, can talk in phrases. 3. IMMUNIZATION 1 dose BCG, 2 doses Hepa B, 2 doses DPT, and 2 doses of OPV. 4. FEEDING HISTORY Patient was currently given Alaska milk with solid food. 5. PAST ILLNESS (+) episodes of seizures upon the height of fever which occurred on first on the 3 rd month of life and 4 other episodes on separate occasions. FAMILY HISTORY: Mother of patient denies having any heredofamilial diseases. PHYSICAL EXAMINATION: GENERAL SURVEY: awake, irritable, oriented to three spheres VITAL SIGNS: HR =112 bpm RR= 34 cpm Temp= 36.5 C BP= 100/70 WEIGHT: 13 kg SHEENT: pink conjunctivae, dry lips/mucosa CHEST: Symmetrical chest expansion,clear breath sounds, no adventitious sounds HEART; Adynamic precordium,normal rate regular rhythm, no murmur ABDOMEN: soft abdomen, (+) tenderness at epigastric area, palpable liver edge 2-3 cm below subcostal margin GUT: no gross genitourinary deformity EXTREMITIES: grossly normal extremities, full equal pulses, (+) blanching on all extremities, (+) macular petechial rashes on the upper extremities, (+) petechial rashes on the lower extremities. ASSESMENT: Dengue Hemorrhagic Fever II PLAN: For admission Patient was admitted to Pedia PICU under the service of Dr. Troncales/Sollaman/Manalo. Patient was monitored VSq1, BP monitoring was included and recorded. Patient was allowed on DAT except dark foods. Patient was started on D5LR 1L at a rate of 65 ugtts/min (5cc/hr). Patient was given Ranitidine 13 mg IV q8, Paracetamol 125 mg/5 ml; 6 ml for T≥ 37.8 C. patient was watched out for bleeding, hypotension, narrow pulse pressure. COURSE IN THE WARDS: On the 1st hospital day, patient was maintained on IVF D5LR 1L to run at 65 cc/hr. patient was for repeat of CBC with PC. Patacetamol was given at 250 mg/ml; 4 ml q4 for T ≥ 37.8 C. vital signs were monitored q2 (BP included). Patient was watched out for hypotension, narrow pulse, bleeding episodes. SUMMARY OF LABORATORY RESULTS CBC with PC WBC RBC HGB HCT PLATELET NEUTROP LYMPHO MONO EOSINO BASOPH Normal Values 6.0-17.5 3.7-5.3 110-140 0.30-0.40 150-400 0.12-0.41 0.46-0.78 0.02-0.09 0.00-0.04 0.00-0.002 5/28 9.5 5.9 15 42.9 101 36.6 37.3 26 0 0.1 PT05/28/08 36.7 (NV = 26-42) CLINICAL CHEMISTRY CALCIUM MAGNESIUM SODIUM POTASSIUM CHLORIDE CREATININE KINASE MB CSF ANALYSIS CSF PROTEIN CSF GLUCOSE COLOR TRANSPARENCY WBC POLYMORPHONUCLEAR CELLS LYMPHOCYTES ULTRASOUND 5/26/08: Sonographically Normal Transcranial Ultrasound Study URINALYSIS PHYSICAL Color Transparency MICROSCOPIC Epithelial cell Mucus Thread Amorh. Urates Pus cells Erythrocytes Yeast cells BLOOD CULTURE SENSITIVITY .
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