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24 HOUR -magsino

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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARMENT OF PEDIATRICS Patient Name: Magsino, Marc John Address: 2637 EB Harrison St., Malate Manila Age/Sex: 3 year-old/male Date Admitted: May 18, 2007 Admitting Diagnosis: Aspiration pneumonia secondary to ND Physician–in-charge: Dr. Benneth Wingsing CIC: JI Jenny Vi H. de Castro CLINICAL ABSTRACT This is a case of a 3 year old female who was admitted due to difficulty of breathing. History of Present Illness 30 minutes PTC, patient was playing when his playmate accidentally pushed him into a sewer. Patient was immersed in H2O for about 10 mins., was then immediately brought to this institution. Review of Systems General: (-) weight loss, loss of appetite SHEENT: no excessive lacrimation, no epistaxis Respiratory: (+) cough production, (+) cold with greenish discharge x 4 in a day. Gastrointestinal: no vomiting, no abdominal pain Genitourinary: no discharge Nervous/ Behavioral: no convulsions Musculoskeletal: no swelling of joint, bone or muscle Hematologic: no pallor, no spontaneous bleeding Past Medical History: Denied any previous hospitalizations, allergies, blood transfusion Had BCG, DPT 123, Measles and OPV as immunization. Birth history: Prenatal: 20 yr old mother G5P5 (5005), (+) PNCU at LHC, (-) maternal illness Natal: Live baby boy, born full term via NSD at Gat Andress hospital. Postnatal: good cry, good activity, no jaundice Feeding: breast fed from birth upto 3 mos., currently bottle feeding with bonamil Immunization: (+) BCG, (+) DPT, (+) Hepa B Family History: Denies heredofamilial diseases. Hospital No. 1687933

Physical Examination: Gen: asleep, not in cardiorespiratory distress VS: CR: 108 RR: 34 T: 37.4°C Skin: (+)skin tenting, no pallor, not jaundiced HEENT: sunken eyeballs, anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy Chest and Lungs: Symmetrical chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: globular, soft, normoactive bowel sounds, soft, nontender, no mass Extremities: grossly normal, full and equal pulses, no edema, no cyanosis

Assessment:

AGE with some signs of Dehydration

Plan: For Admission

Course in the Ward: Upon admission, the patient had sunken eyeballs. Present milk formula was shifted to NAN HA and patient was fed with strict aspiration precaution. Diagnostics done: CBC with PC, blood typing, urinalysis, chest x-ray, PFA, and fecalysis. IV fluids: D5 IMB 500 cc at rate of 26-27 cc/hr. Therapeutics: Ampicillin 160 g IV. Vital signs were monitored every 6 hours. On the first hospital day, patient had good suck, afebrile, no vomiting and no fever. IV fluids was shifted to PNSS. IV medications were continued. Laboratory Results: CBC WBC RBC HGB HCT MCV MCH MCHC PLATELET Neutrophils Lymphocytes Monocytes Eosinophils Basophils April 27 18.8 2.5 8.5 25 67.4 21.7 32 243 44.8 48.1 5.6 1.1 0.4

FECALYSIS: May 13, 2007 Microscopic Color: yellow Pus: 1.2 RBC: 0-1 Consistency: watery Ova/Parasite: no ova or parasite seen Urinalysis: May 14, 2007 Color: yellow Transparency: clear EP: occasional MT: few AU: occasional PC: 0-1 Erythrocytes: 0-1 Albumin (-) Sugar:(-) SG: 1.025 pH: 6.0


				
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