Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: Lumanga, Sean Robert Address: 341 E. Quintos St., Samplaoc, Manila Age/Sex: 2 mo/male Date Admitted: May 22, 2008 Admitting Diagnosis: Pneumonia, probably aspiration Physician–in-charge: Dr. Salloman/Dr. Manalo Clerk-in-charge: Erum/Fernando/Figueras/Fuentes/Cuvin
24 hour history This is a case of a live baby , born full term to an 18year-old G1P1 (1-0-0-1) mother, via NSD at OMMC, who came in due to difficulty of breathing. HISTORY OF PRESENT ILLNESS Ten days PTA, patient was admitted at Ospital ng Sampaloc for perinatal pneumonia, was given Pen G and Gentamycin for 7 days. 3 days PTA, patient was discharged apparently still with cough but with no take home meds given. 2 days PTA, patient had 1 episode of cyanosis. He was again rushed to Ospital ng Sampaloc and was sunsequently admitted. Patient was prescribed with Cefuroxime. Persistence of symptoms and due to patient’s demand, patient was transferred to this institution. PAST MEDICAL HISTORY: Pre-natal/Birth: Patient is a first born child, born full-term to an 18 year old G1P1 (1-0-0-1) mother via normal spontaneous delivery at OMMC. Mother had regular prenatal checkups. There were no known illnesses and complications during the course of the pregnancy. Feeding and Nutrition: patient was fed with Nestogen 1 since birth at 1:1 dilution. Immunization: (+) BCG, (+) Hepa B x 1 FAMILY HISTORY/ PERSONAL AND SOCIAL HISTORY: (+) PTB, (+) asthma - aunt The patient’s mother denies any family history of diabetes mellitus, cardiac disease PHYSICAL EXAMINATION: General: awake, active, not in cardiorespiratory distress Vital Signs: HR = 154 RR = 33 Temp = 36.4 0C Weight = 5 kg Extremities: grossly normal, (-) cyanosis, (-) edema, (-) polydactylism, (-) syndactylism, (-) club foot, (+) full and equal pulses SHEENT: good skin turgor, anicteric sclera, pink palpebral conjunctiva, (+) CLAD, (+) neck mass posterolateral side, Right, warm to touch, erythematous, hard, tender, nonmovable, 4x5 inches in size Chest/Lungs: SCE, (+) occasional retractions, (+) harsh breath sounds Cardiac: adynamic precordium, NRRR, no murmur Abdomen: globular, NABS, soft, nontender Extremities: grossly normal extremities, full pulses, no cyanosis, no edema Reflexes: (+) moro, (+) sucking, (+) grasping ASSESSMENT: Pneumonia, probably aspiration PLAN: For admission
Patient was admitted at the Pedia-Infirmary under the service of Drs. Troncales/Salloman/Manalo. Patient was placed on NPO temporarily and was hooked to D5IMB 500cc to run at a rate of 26-27 ugtts/min. Diagnostics requested were CBC with PC, BT, CXR APL, Blood CS. Medication given were: Cefuroxime 250 mg IV q12, Salbutamol nebulization every 4 hours, Paracetamol 100mg/ml 0.5ml q4 for fever > 37.8oC. Vital signs were monitored every 4 hours. On the 1st HD, patient was allowed feeding with SAP. Nebulization was decreased to q6, chest physiotherapy done every after nebulization. Medications were continued. Vital signs were monitored every 4 hours.