rosaldo ca by dredwardmark


									Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila

Patient’s Name: Rosaldo, John Mark Christian L. Age/Sex: 4 month old/M Address: 1131 D. Eugenio St. Otis Paco Manila Date Admitted: May 28, 2008 Admitting Diagnosis: Acute Bronchiolitis Physicians–in-charge: Dr. Troncales/Dr. Salloman/Dr. Manalo Clerks-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez CLINICAL ABSTRACT

Hospital No. 1841375

HISTORY OF PRESENT ILLNESS This is a case of a 4 month old male born to a 28 year old G3P3 (3003) mother via NSD on January 4, 2008 and was brought to Pedia ER OMMC due to difficulty of breathing. The patient was apparently well until… One day PTA, patient developed fever, undocumented, and was given Paracetamol (60 mkd) which offered relief. Patient also had productive cough and colds with clear discharge. No consult was done. Few hours PTA, symptoms mentioned persisted. Patient was also observed to have difficulty of breathing described as chest indrawing, and bobbing of head and alar flaring. Thus, prompted consult. PAST MEDICAL HISTORY 1. PRENATAL/BIRTH HISTORY Patient was born full term to a mother who had regular prenatal check up at the Local Health Center, and denies having any disease while on the course of her pregnancy. No fetomaternal complications. 2. FEEDING HISTORY: Breast fed x 1 wk shifted to Bonna 1:1 dilution then to Nestogen with 1:1 dilution. 3. IMMUNIZATION (+) BCG (+) DPT – 3 doses (+) OPV – 3 doses (+) Hepa B – 2 doses 4. DEVELOPMENTAL HISTORY At par with age. 5. PAST MEDICAL ILLNESS No previous hospitalizations. 6. FAMILY HISORY No allergy, no asthma, no PTB PHYSICAL EXAMINATION: GENERAL SURVEY: asleep, in moderate respiratory distress VITAL SIGNS: HR =120 bpm RR= 76 cpm Temp= 36.5 C SHEENT: anicteric sclera, pink palpebral conjunctiva, no NAD, no TPC, no CLAD, (+) head bobbing CHEST: Symmetrical chest expansion, (+) subcostal retractions, (+) crackles all lung fields HEART; Adynamic precordium,normal rate regular rhythm, no murmur ABDOMEN: globular, soft, non tender abdomen GUT: no gross genitourinary deformity EXTREMITIES: grossly normal extremities, full equal pulses, no edema, no cyanosis ASSESMENT: Acute Bronchiolitis t/c Pneumonia PLAN: For admission Patient was admitted to Pedia PICU under the service of Dr. Troncales/Sollaman/Manalo. Patient was monitored VSq2. I and O recorded. Patient was maintained on NPO. Laboratories requested are the following: CBC with PC, BT, chest X-ray AP/L. Patient was started on IVF D5 0.3 NaCl 1L at 30 ugtts/min. Patient was started on nebulization of Salbutamol 1 nebule every 4 hours. Patient was given Paracetamol 100 mg, 0.8 ml q4 for T ≥ 37.8 C

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