Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: Elape, Henrick John Address: 2375 Tejeron St. Sta. Ana, Manila Age/Sex: 5 mo./male Date Admitted: June 2, 2008 Admitting Diagnosis: Bronchial Asthma in acute exacerbation t/c Pneumonia Physician–in-charge: Dr.Nunez/ Arollado/Reyes Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 1835103
CLINICAL ABSTRACT This is a case of a 5 year-old male, known asthmatic, was brought in due to difficulty of breathing. HISTORY OF PRESENT ILLNESS 1 day PTA, patient was exposed to fumigation after a few hours after which patient had cough and difficulty of breathing. There was no fever, vomiting nor diarrhea noted. He was nebulized with Salbutamol with every few hours which partiall relieved the symptoms. Few hours prior to consult, the mother noted the increase in severity of the patient, hence, consult. PAST MEDICAL HISTORY Patient was admitted 2 weeks prior to consult at OMMC due to pneumonia and AGE with moderate signs of dehydration and was medicated with Ampi-sulbactam. He was sent home with the following home medication: Co-amoxiclav for 7 days with good compliance. IMMUNIZATION HISTORY 1 dose of BCG only FAMILY HISTORY (+) asthma – maternal side (+) exposure to cigarette smoking PRENATAL/NATAL/POSTNATAL HISTORY Patient was born full-term to a G5P5 (5005) via NSD at OMMC with no complications. Mother had prenatal check-up on the 3rd month AOG and was noted with spotting and was given unrecalled meds. DEVELOPMENTAL HISTORY At par with age. PHYSICAL EXAMINATION: General: awake, ICRD Vital Signs: HR = 104 RR = 74 Temp = 37.20C Wt: 6.8 kg SHEENT: rash around neck area, good skin turgor, anicteric sclera, pink palpebral conjunctiva, no tonsillopharyngeal congestion, (+) cervical lymphadenopathy, (+) nasoaural discharge Chest/Lungs: SCE, (-) retractions, (+) crackles on all lung fields Cardiac: adynamic precordium, NRRR, no murmur Abdomen: globular, NABS, soft, no tenderness Extremities: grossly normal extremities, full equal pulses, (-) edema, (-) cyanosis ASSESSMENT: Pneumonia, severe with hyperreactive airways t/c PPTB disease PLAN: For admission
Patient was admitted at Pedia ward rm. 422 under the service of Drs. Nunez/Arollado/Reyes. Patient was placed on NPO temporarily. IVF given was D5 IMB 680ml to run for 24 hours at 28-29 ugtts/min. Laboratories requested were CBC/PC, CXR-APL, and U/A. Medications started were: Hydrocortisone 50mg TIV then 30mg TIV q6 (LD=7.3, MD=4.4) Salbutamol Nebule q4, with gentle CPT after neb. O2 support was given via nasal cannula at 2cpm. I/O was monitored q4. Secretions were suctioned PRN. VSq2.