Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: SUMAGAYSAY, Jen Age/Sex: 1 month/F Address: 1055 Dagupan St. Tondo, Manila Date Admitted: June 4, 2008 Admitting Diagnosis: Acute Gastroenteritis with severe signs of DHN; Sepsis Neonatorium, late onset Physicians–in-charge: Dr. Nunez/Arollado/Reyes Clerks-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 1843792
48 HOUR HISTORY This is a case of a 1 month old female born full term to a 21 year old G2P2 (2002) via NSD at OMMC who came in due to poor feeding HISTORY OF PRESENT ILLNESS Eight days PTA, patient had loose watery stools, yellowish, non foul smelling, non bloody, non mucoid. Mother brought the patient to a local health center and was prescribed with ORS. Patient had good suck, no fever. He had one bout of vomiting, non projective non bloody, of previously ingested food. Four days PTA, patient did not have any episode of vomiting and loose bowel movement more than 3 episodes of greenish, semiformed stools (non bloody) with poor suck, poor appetite. Patient had difficulty of breathing. Patient was then brought again to the local health center and was referred to OMMC. PRENATAL/NATAL/POSTNATAL Mother did not have pre natal check ups, no medications taken, no maternal illnesses. IMMUNIZATION Patient had received Hepa B immunization and BCG. FEEDING Patient was bottle fed with Bonna 1:1 since birth. GROWTH AND DEVELOPMENT At par with age. PAST MEDICAL HISTORY No previous hospitalization, no allergies FAMILY HISTORY No seizure disorder, no DM, no bronchial asthma, no PTB, no allergies PHYSICAL EXAMINATION: GENERAL SURVEY: drowsy, irritable VITAL SIGNS: HR =116 bpm RR= 68 cpm Temp= 35 °C SHEENT: poor skin turgor wit h rashes in the genital area, atraumatic head, normocephalic, depressed anterior fontanelles, sunken eye balls, dry oral mucosa CHEST: symmetrical chest expansion, (+) chest indrawing, clear breath sounds HEART; Adynamic precordium, normal rate regular rhythm, (-) murmur GIT: slightly distended abdomen, hyperactive bowel sounds, (+) tenting EXTREMITIES: cold clammy extremities ASSESMENT: Acute Gastroenteritis with severe signs of dehydration Sepsis Neonatorium, late onset PLAN: For admission Patient was admitted to Pedia Ward at PICU under the services of Dr.Nunez/Arollado/Reyes. Vital signs monitoring was done q1. Patient was maintained on NPO. IVF to ff: D5 0.3 NaCl 170 ml x 5 hours to run at 34-35 cc/hr (mod). O2 support via funnel at 4-5 lpm. Diagnostics: CBC with PC, Urinalysis, Fecalysis, CXR AP/L to include abdomen, Blood CS, Na, K. Medications are: Ampicillin 100 mg q8 TIV (130 mkd), Gentamicin 10 mg q24 TIV (4.3 mkd), Metronidazole 40 mg q8 TIV (52.2 mkd), Ranitidine 3 mg TIV q8. Hgt while on NPO q12. OGT was inserted and kept open. Foley catheter was inserted and was requested for I and O monitoring. Course in the PICU: On the 1st hospital day, IVF was revised as follows: PNSS 57 cc to run for 1 hour. If with (-) urine output, patient was to be given D5 NSS at 36-37 ugtts/min. If with urine output, patient was to be given D5 0.3 NaCl to run at 36-37 ugtts/min. Hgt was monitored. O2 support was maintained. Medications were continued except for metronidazole. Assessment was changed to AGE with some signs of dehydration, t/c sepsis neonatorum. On the 2nd hospital day, patient was was started on milk feeding, 5 cc every 3 hours. O2 support was discontinued. Gentamycin was continued. Patient was for possible transfusion of 1 unit fresh frozen plasma. Patient was for lumbar puncture. OGT was discontinued. Vital signs were monitored every hour. Ampicillin was shifted to ceftazidime 115 mg SIVP every 12 hours.