Ospital ng Maynila Medical Center Department of Surgery Quirino Avenue cor Roxas Boulevard Manila, Philippines
Name: Lasutan, Jhon Mark Age/Sex: 8 months Address: Intramuros, Manila Date Admitted: April 25, 2009 Admitting Diagnosis: Cellulitis Inguinoscrotal Area, Right Physicans-in-charge: Dr. Cruz/ Balucating/ Sunaz/ Lucero/ Caravana Clerks-in-charge: JI Javier/Jose/Kashim/Lazaro/Libiran/Lintag/Loria 24 hour histoy
Hospital No.632349 Ward/Room No. Sx- 305
Thisis is a case of 1 year old male from Intramuros Manila who was brought in due to soft tissue swelling in the inguinoscrotal area, right. History of Present Illnessc 3 days prior to admission, patient noted erythema on the right inguinal area. It was warm to touch, tender, and was allegedly due to an insect bite. No consult was done and no medications were taken. 3 days prior to admission, patient noted progression of swelling of the rightb inguinal area with associated fever noted to be at 38-39 C. Patient was given Paracetamol which provided relief of pain. 1 day prior to admission, progression of swelling up to the right scrotal area, patient was also noted to be irritable. Peristence of symptoms prompted consult. Hence, this admission. Past Medical History (+) Pneumonia, 2008 - admitted at OMMC (-) HPN, DM, allergies on drugs, operations (-) known allergy to food and drugs Family History Denies heredofamilial disease Personal and Developmental History Patient is at par with age Review of Systems: unremarkable Physical Examination General: patient was awake, coherent, oriented, not in cardiorespiratory distress. Vital Signs: HR 120 RR 22 temp 37.5 weight 8.5kg HEENT: anicteric sclerae, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no nasoaural discharge Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds. Cardio: Adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: Flabby, NABS, soft, (-) tenderness Extremities: no cyanosis, no edema, grossly normal Genito urinary: (+) soft tissue swelling, scrotal area, right Assessment: Cellulitis scrotal area, right
Plan: Patient was for admission and management under the service of Drs. Go/ Cruz/ Gonzales/ Malabanan/ Jawali/ Caravana . Consent was secured. Patient was on diet for age. IVF was given D5 0.3 NaCl 285ml at 35-36 gtt/min as his IVF. He was given Oxacillin 110mg TIV every 6 hours (-) ANST and Paracetamol 100mg TIV every 4 hours for pain. The following diagnostics were requested: CBC with Platelets Course in the Wards; On the 1st day of admission, patient was seen by pediatrics. He was assessed as abscess/ cellulitis/ lymphadenitis scrotal area right with protein malnutrition.Paracetamol was decreased 100mg TIV every 6 hours for pain and OR every 4 hours. Oxacillin was increased to 250mg TIV for 6 hours.
Ospital ng Maynila Medical Center Department of Surgery Quirino Avenue cor Roxas Boulevard Manila, Philippines
Name: Lasutan, Jhon Mark Age/Sex: 8 months Address: Intramuros, Manila Date Admitted: April 25, 2009 Admitting Diagnosis: Cellulitis Inguinoscrotal Area, Right Physicans-in-charge: Dr. Cruz/ Balucating/ Sunaz/ Lucero/ Caravana Clerks-in-charge: JI Javier/Jose/Kashim/Lazaro/Libiran/Lintag/Loria 48 hour histoy
Hospital No.632349 Ward/Room No. Sx- 305
Thisis is a case of 1 year old male from Intramuros Manila who was brought in due to soft tissue swelling in the inguinoscrotal area, right. History of Present Illnessc 3 days prior to admission, patient noted erythema on the right inguinal area. It was warm to touch, tender, and was allegedly due to an insect bite. No consult was done and no medications were taken. 3 days prior to admission, patient noted progression of swelling of the rightb inguinal area with associated fever noted to be at 38-39 C. Patient was given Paracetamol which provided relief of pain. 1 day prior to admission, progression of swelling up to the right scrotal area, patient was also noted to be irritable. Peristence of symptoms prompted consult. Hence, this admission. Past Medical History (+) Pneumonia, 2008 - admitted at OMMC (-) HPN, DM, allergies on drugs, operations (-) known allergy to food and drugs Family History Denies heredofamilial disease Personal and Developmental History Patient is at par with age Review of Systems: unremarkable Physical Examination General: patient was awake, coherent, oriented, not in cardiorespiratory distress. Vital Signs: HR 120 RR 22 temp 37.5 weight 8.5kg HEENT: anicteric sclerae, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no nasoaural discharge Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds. Cardio: Adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: Flabby, NABS, soft, (-) tenderness Extremities: no cyanosis, no edema, grossly normal Genito urinary: (+) soft tissue swelling, scrotal area, right Assessment: Cellulitis scrotal area, right
Plan: Patient was for admission and management under the service of Drs. Go/ Cruz/ Gonzales/ Malabanan/ Jawali/ Caravana . Consent was secured. Patient was on diet for age. IVF was given D5 0.3 NaCl 285ml at 35-36 gtt/min as his IVF. He was given Oxacillin 110mg TIV every 6 hours (-) ANST and Paracetamol 100mg TIV every 4 hours for pain. The following diagnostics were requested: CBC with Platelets Course in the Wards; On the 1st day of admission, patient was seen by pediatrics. He was assessed as abscess/ cellulitis/ lymphadenitis scrotal area right with protein malnutrition.Paracetamol was decreased 100mg TIV every 6 hours for pain and OR every 4 hours. Oxacillin was increased to 250mg TIV for 6 hours. On the 2nd day of admission, the patient was still for diet for age. IVF given was D5 IMB 1L at 35-36 ugtt/min.
Ospital ng Maynila Medical Center Department of Surgery Quirino Avenue cor Roxas Boulevard Manila, Philippines
Name: Lasutan, Jhon Mark Age/Sex: 8 months Address: Intramuros, Manila Date Admitted: April 25, 2009 Admitting Diagnosis: Cellulitis Inguinoscrotal Area, Right Physicans-in-charge: Dr. Cruz/ Balucating/ Sunaz/ Lucero/ Caravana Clerks-in-charge: JI Javier/Jose/Kashim/Lazaro/Libiran/Lintag/Loria Patient Discharge Summary
Hospital No.632349 Ward/Room No. Sx- 305
Thisis is a case of 1 year old male from Intramuros Manila who was brought in due to soft tissue swelling in the inguinoscrotal area, right. History of Present Illnessc 3 days prior to admission, patient noted erythema on the right inguinal area. It was warm to touch, tender, and was allegedly due to an insect bite. No consult was done and no medications were taken. 3 days prior to admission, patient noted progression of swelling of the rightb inguinal area with associated fever noted to be at 38-39 C. Patient was given Paracetamol which provided relief of pain. 1 day prior to admission, progression of swelling up to the right scrotal area, patient was also noted to be irritable. Peristence of symptoms prompted consult. Hence, this admission. Past Medical History (+) Pneumonia, 2008 - admitted at OMMC (-) HPN, DM, allergies on drugs, operations (-) known allergy to food and drugs Family History Denies heredofamilial disease Personal and Developmental History Patient is at par with age Review of Systems: unremarkable Physical Examination General: patient was awake, coherent, oriented, not in cardiorespiratory distress. Vital Signs: HR 120 RR 22 temp 37.5 weight 8.5kg HEENT: anicteric sclerae, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no nasoaural discharge Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds. Cardio: Adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: Flabby, NABS, soft, (-) tenderness Extremities: no cyanosis, no edema, grossly normal Genito urinary: (+) soft tissue swelling, scrotal area, right Assessment: Cellulitis scrotal area, right
Plan: Patient was for admission and management under the service of Drs. Go/ Cruz/ Gonzales/ Malabanan/ Jawali/ Caravana . Consent was secured. Patient was on diet for age. IVF was given D5 0.3 NaCl 285ml at 35-36 gtt/min as his IVF. He was given Oxacillin 110mg TIV every 6 hours (-) ANST and Paracetamol 100mg TIV every 4 hours for pain. The following diagnostics were requested: CBC with Platelets Course in the Wards; On the 1st day of admission, patient was seen by pediatrics. He was assessed as abscess/ cellulitis/ lymphadenitis scrotal area right with protein malnutrition.Paracetamol was decreased 100mg TIV every 6 hours for pain and OR every 4 hours. Oxacillin was increased to 250mg TIV for 6 hours. On the 2nd day of admission, the patient was still for diet for age. IVF given was D5 IMB 1L at 35-36 ugtt/min. On the 3rd day of admission, the patient still on DAT. Cintinue IVF hydration and Iv medications. Iv line was reinserted. On the 4th day of admission, the patient was given Oxacillin. Vital signs were monitored evrey 4 hours. On the 5th day of admission, medications were continued. IVF and IV medications were continued. Bedside I and D was done. On the 6th day of admission, patient specimen was sent for lab for GS/CS, AFB. IVF and IV medications were ccontinued. On the 7th day of admission, patient continued IVF and Iv medications. Patient was for daily wound care/ Vital signs were monitored. On the 8th-11th day of admission, patient's management were continued. Patient was advised for daily wound cleaning. Diet was for age. On the 12th day of admission, the patient was allowed to go home. Oral medications were continuedd ar home. Patient was to come back after 1 week.