Flores CA by dredwardmark


									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila

Patient’s Name:Flores, Danica Mae Address: 2174 F. Munoz St. San Andres Malate, Manila Age/Sex: 16/F Date Admitted: June 9, 2008 Admitting Diagnosis: Amoebiasis with mild Dehydration Final Diagnosis: Physician–in-charge: Dr. Nuñez/Arollado/Reyes Clerk-in-charge: Fabian/Ilarde/Ingles/Item/Junsay

Hospital No.1845692

Clinical Abstract This is a case of a 16 year old female who was brought in due to vomiting and diarrhea. HISTORY OF PRESENT ILLNESS 2 days PTA, patient had undocumented fever with associated loss of appetite. There was no generalized weakness, no cough, no colds, no vomiting, no diarrhea. No consult and medication given. 1 day PTA, there was persistence of fever with associated vomiting of previously ingested food, loose watery stools described as brown, nonbloody, 4-5 times and flank pain. Persistence of the above symptoms prompted them to consult at the Ospital ng Maynila Medical Center Pedia ER where they were subsequently admitted. PAST MEDICAL HISTORY No previous hospitalization FAMILY HISTORY No hereditofamilial diseases PERSONAL AND SOCIAL HISTORY: Patient is an active teenager, nonsmoker and nonalcoholic beverage drinker. Review of Systems Gen: no weight loss, no anorexia, HEENT: no headache, no dizziness, no blurring of vision, no tinnitus, no epistaxis, no dysphagia, Respiratory: no cough, no colds, no DOB Cardiovascular: no chestpains, no palpitations, no orthoponea GUT: no dysuria, no oliguria, no hematuria Endo: no polyuria, no polyphagia, no polydipsia Hema: no easy bruisability MSS: no myalgia, no arthralgia PHYSICAL EXAMINATION: General: Patient is conscious, coherent, not in cardiorespiratory distress Vital Signs: HR = 118 RR = 20 Temp = 38.90C BP: 100/60 SHEENT: anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge, no tonsillopharygngeal congestion, no cervical lymphadenopathy Chest/Lungs: symmetric chest expansion, (-) retractions, clear breath sounds Cardiac: adynamic precordium, tachycardic, normal rhythm, no murmur Abdomen: flat, NABS, soft, (+)CVA tenderness, (-) psoas, (-) obturator sign Extremities: no cyanosis, no edema, full and equal pulses ASSESSMENT: Amoebiasis with mild dehydration PLAN: For admission Patient was admitted at the Pedia Infirmary under the services of Drs. Nuñez/Arollado/Reyes. Diet as tolerated IVF: D5LR 1L to run at 28 ugtts/min Labs Requested: CBC PC, Fecalysis

Urinalysis Medications: Metronidazole 750mg/IV in push x 15min q8 (45mkd) Ranitidine 1 amp IV q8 Paracetamol 1 amp q4 prn T>37.8 Monitor frequency and consistency of stool and record Monitor VS q4

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