Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: Matuan, Arssad Age/Sex: 1 month old/ M Address: Globo de Oro Quiapo, Manila Date Admitted: May 28, 2008 Admitting Diagnosis: Acute Gastroenteritis with Moderate dehydration t/c Sepsis Physicians–in-charge: Dr. Troncales/Dr. Salloman/Dr. Manalo Clerks-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez PATIENT DISCHARGE SUMMARY
Hospital No. 1841394
This is a case of a 1 month old baby boy born on April 23, 2008 to a 33 year old G3P3 (2103) mother via NSD AT East Avenue Hospital and currently residing at Globo de Oro St. Quiapo, Manila who came in due to rolling of eyeballs and cicumoral cyanosis. HISTORY OF PRESENT ILLNESS The patient was apparently well until… 5 days PTA, patient started to have loose watery stool, characterized as yellow, non mucoid, non bloody, non foul smelling stools, 4 episodes about ½ cup per bout. No fever, no vomiting, no abdominal distension. No medications given and consult done. 2 days PTA, patient’s symptoms mentioned still persisted that prompted to seek consult at the local heath center. Patient was given Glucolyte with vol./vol. replacement and breastfeeding. No fever, no vomiting. Few hours PTA, passage of loose watery stool still persisted, with vomiting 2 episodes of previously ingested meals. Patient was not able to tolerate milk feeding. Patient had circumoral cyanosis with rolling of the eyeballs but no note of stiffening of extremities. They sought consult at PGH but was given THOC form thus consult at the Pedia ER at OMMC where the patient was subsequently admitted. PAST MEDICAL HISTORY 1.BIRTH HISTORY Mother had prenatal check-up ( 5 times) at a local Health Center. She took Multivitamins and Ferrous sulfate at her 4th month of pregnancy. At 5 months AOG, mother was diagnosed with UTI at PGH and denies taking any antibiotics. 2. NATAL HISTORY Patient was born at 7 months to a 33 year old G3P3 (2103) mother with no feto-maternal complications 3. IMMUNIZATION HISTORY Mother reported patient had no immunization yet. 4. FEEDING HISTORY Exclusively breastfed since birth and was given BONA 1:1 dilution 4 days prior to admission. 5. DEVELOPMENT At par with age. 6. PAST ILLNESS No previous hospitalization. FAMILY HISTORY: (+) Bronchial Asthma – paternal side No other heredofamilial diseases PHYSICAL EXAMINATION: GENERAL SURVEY: awake, irritable, in moderate respiratory distress VITAL SIGNS: HR =125 bpm RR= 60 cpm Temp= 36.1 ANTHROPOMETRICS: Weight: 3.25 Length: 46 cm HC: 38 CC: 33 AC: 34 SHEENT: anicteric sclera, pink palpebral conjunctiva, sunken anterior fontanel, dry lips and mucosa, sunken eyeballs, (-) nasoaural discharge, (+) tonsillopharyngeal congestion, (-) cervical lymphadenopathy CHEST: Symmetrical chest expansion, tachypneic, clear breath sound HEART; Adynamic precordium, tachycardic, regular rhythm, (-) murmur ABDOMEN: globular, soft, normoactive bowel sounds, non tender, (+) skin tenting EXTREMITIES: grossly normal extremities,weak pulses, no edema, (+) cyanosis. ASSESMENT: Acute Gastroenteritis with moderate dehydration t/c sepsis PLAN: For admission Patient was admitted to Pedia PICU under the services of Dr. Troncales/Dr. Salloman/Dr. Manalo. Vital signs monitoring was done q1. Patient was placed on NPO. Laboratories requested are: CBC with PC, BT, UA, FA, Blood CS, LP, serum Na and K. IVF D5 IMB 500cc at a rate of 16-17
ugtt/min (125%). Medications are: Ampicillin 160 mg/IV q6 (200 mkd), Gentamicin 8 mg IV q12 (5 mkd), Metronidazole 50 mg IV q8 (50 mkd), Phenobarbital 32 mg IV (10 mkd) then 8 mg q12 (5 mkd). May be given Diazepam 0.6 mg IV for frank seizure. O2 support via nasal cannula at 2 pm. Requires thermoregulation at all times. COURSE IN THE WARDS: On 1st hospital day, patient was still on NPO, was given D10W 6 cc via SIVP. Patient was placed on O2 hood at 10pm. Revised IVF:: D5 IMB – 427, D50-50 – 53 = 480 cc X 24hours at 20 cc/hr. Hgt was monitored q8 while on NPO. Refer if it’s less than 40 mg/dL. Laboratories requested: repeat CBC and PC, blood CS, serum Na, K, Ca, Mg. CSF analysis, fecalysis, urinalysis, PFA, cranial ultrasound. Patient was started with Meropenem 150 mg SIVP q8 (46 mkd). Ampicillin was discontinued, Gentamicin, and Metronidazole were continued. Patient was referred to surgery for further evalustion and management. Vital signs monitored VS q1 and was put on close watch. SUMMARY OF LABORATORY RESULTS CBC with PC Normal Values 5/29 WBC 8.0-38.0 X 109/L 8.0 RBC 4.6-6.6 X 1012/L 2.0 HGB 150-220 g/L 60 HCT 40 – 54 % 0.17 PLATELET 150-400 X 109/L 164 NEUTROP 0.23-0.77 36.1 LYMPHO 0.25-0.36 58.2 MONO 0.02-0.09 5.7 EOSINO 0.00-0.04 0.0 CLINICAL CHEMISTRY CALCIUM MAGNESIUM SODIUM POTASSIUM CHLORIDE CREATININE KINASE MB
CSF ANALYSIS CSF PROTEIN CSF GLUCOSE COLOR TRANSPARENCY WBC POLYMORPHONUCLEAR CELLS LYMPHOCYTES
ULTRASOUND 5/26/08: Sonographically Normal Transcranial Ultrasound Study URINALYSIS PHYSICAL Color Transparency MICROSCOPIC Epithelial cell Mucus Thread Amorh. Urates Pus cells Erythrocytes Yeast cells BLOOD CULTURE SENSITIVITY .