Lazaro_ I.-pds.shin by dredwardmark

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS

Name: LAZARO, IMAN Age/Sex: 8mos/F Address: Quiapo, Manila Date of Admission: May 20, 2008 Admitting Diagnosis: Pneumonia, Severe Date of Discharge: May 28, 2008 Final Diagnosis: Pneumonia, Severe PTB III Residents-in-charge:Dr. Troncales/ Dr. Salloman/ Dr. Manalo Clerks-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez

Hospital No. 1837671

PATIENT’S DISCHARGE SUMMARY This is a case of an 8 month-old girl currently residing at Quiapo, Manila who came in due to persistent cough. History of Present Illness: 3 weeks PTA, patient had fever undocumented (hot to touch) with productive cough with mcoid nasal discharge. Patient was given Paracetamol at 9.7 mkd, fever was temporarily relieved. 2 weeks PTA, symptoms persisted. Patient was brought to a local doctor for consult. Impression was Pneumonia. Patient was given Salbutamol (0.08 mkd) every 6 hours and Cefaclor. Symptoms resolved, decreased cough and relief of fever when antibiotics was given. 6 days PTA, symptoms persisted. Medications were given with poor compliance. 1 day PTA, symptoms worsened. Patient had undocumented fever with dyspnea, hence consult OMMC-ER and subsequently admitted. Review of Systems: (-) seizures (-) cyanosis (+) dyspnea (+) decreased feeding (+) easy fatigability Prenatal/Birth History: Patient was born to a 32 year-old G3P1 (1021) via NSD at OMMC with regular prenatal check-ups. Denies any illness during pregnancy with intake of multiviatmins. Past Medical History: (-) hospitalization Family History: Denies asthma/hypertension Immunization History: (+) BCG 1 dose, Hepa B 2 doses, DPT 2 doses, OPV 1 dose Developmental History: Can crawl backwards Can do social smile Social/ Environmental: Breastfed by mother Can eat semisolid food PHYSICAL EXAM General survey: The patient is awake, irritable and not in respiratory distress. Vital Signs: T=39 C HR= 120 bpm RR=42 cpm Weight: 1.2 kg HEENT: (+)dry lipss & oral mucosa, (-) alar flaring, anicteric sclera, pink palpebral conjunctiva, (-) CLAD Chest:: Lungs- symmetrical chest expansion, minimal subcostal retractions (+) harsh breath sounds Heart: adynamic precordium, normal cardic rate and regular rhytm, (-)murmur Abdomen: globular, soft, normoactive bowel sounds, (-) palpable mass Genitalia: grossly normal findings Extremities: grossly normal findings, full and equal pulses, (-)edema ASSESSEMENT: Pneumonia, Severe PLAN: For admission Patient was admitted to Pediatrics ward at room 420 under the service of Drs. Troncales/ Salloman / Manalo. Patient was put on NPO temporarily. IVF: D5 O.3 NaCl 360mlx 6hours to run at 60 ugtts/min. May have O2 support via cannula at 2lpm. Laboratory exams requested were CBC PC, CXR AP/L. Medications were: Ampicillin 180mg TIV q6 100mkd, Salbutamol nebulization q3. WOF progression of respiratory distress. Revised

medications were: Cefuroxime 250mg IV ANST(-), Clarithromycin 125mg/5ml 2.5ml q12 17mkd. Maintained high back rest. IVF TF: D5IMB 500cc to run at 39cc/hr (FM + 30%). Cefuroxime was shifted to Ampicillin sulbactam at 250mg/ SIVP q6 (138 mkd). Started Gentamycin 35mg/SIVP q24 (5mkd). Hydrocortisone 60mg/IV now, then 35mg /IV q6. O2 funnel at 5-6lpm. Increased Salbutamol neb q2, alternate with Combivent q6. For PPD. V/Sq2. On the 1st hospital day, patient was maintained on NPO except medications. IVF: D5IMB 500cc to run at 40cc/hr. O2 was maintained at 56lpm. Maintained Salbutamol nebulization q2 alternate with Combivent q6. Gentle CPT was done after nebulization. IV medications were continued. Ampicillin Sulbactam D1, Gentamycin D2, Hydrocortisone, Clarithromycin. Suction secretion PRN. V/S q2. On the 2nd hospital day, patient had milk feeding at 15cc q3 with SAP. Head was elevated at all times. IVF D5IMB 500cc to run at 39cc/hr. Maintained O2 funnel at 5-6lpm. Nebulized with racemic epinephrine. Salbutamol nebulization was maintained q2 alternate with Combivent q6. Triple antikoch’s was started, INH 200mg/5ml; 1.5ml OD, RIF 200mg/5ml; 2.5ml OD, PZA 250mg/5ml; 2.5ml OD. IV medications were continued. V/S q2. On the 3rd hospital day, breastfeeding was continued with SAP. IVF: D5IMB 500cc at 40cc/hr. O2 support PRN. Salbutamol nebulization was decreased to q3 alternate with combivent q8. IV and nal medications were continued. Ampicillin Sulbactam D2-3, Gentamycin D3, Hydrocortisone, Clarithromycin D2-3, Triple anti-Koch’s. V/S q4. On the 4th hospital day, breasfeeding was continued with SAP. IVF: D5 IMB 500cc to run at 40cc/hr. IV medications were continued. Decreased Salbutamol nebulization q4, alternate with combivent q12. V/S q4. On the 5th hospital day, breastfeeding was continued with SAP. IVF: D5IMB 500cc to run at rate of 30cc/hr. IV medications were continued. Continued Salbutamol nebulization q4, alternate with Combivent q12. CPT post nebulization. V/S q4. On the 6th hospital day, breastfeeding was continued with SAP. IVF: D5IMB 500cc to run at rate of 30cc/hr. IV medications were continued. Decreased Salbutamol nebulization to q6, alternate with Combivent q12. CPT post nebulization. V/S q4. On the 7th hospital day, breastfeeding was continued with SAP. IVF: D5IMB 500cc to run at rate of 30cc/hr to consume then shift to heplock. IV medications were continued. Continued Salbutamol nebulization q4, alternate with Combivent q12. CPT post nebulization. V/S q4. On the 8th hospital day, patient was discharged with the following home medications: 1. Co-amoxiclav 250 mg/5 ml; 2.5 ml BID for 5 days 2. Clarithromycin 125 mg/5 m; 2.5 ml BID for 3 days 3. Trilple Anti-Koch’s To come back for follow-up at the OPD after 5 days

SUMMARY OF LABORATORY RESULTS Complete Blood Count Normal Values Hgb Hct WBC Segmenters Lymphocyte Eosinophil Monocyte Stab Basophil Platelet Bleeding time Clotting time ESR Blood type Peripheral smear May 20, 2008 CXR AP/L Pneumonia Hyperaerated airway 10-160g/dl 36-47 % 4.8- 10.8 x 10 60-70% 30-40% 1-3% 2-8 % 2-6 % 0-1 % 130-400 x 10 1-3 min 1-6 min F 0 -20 mm/hr M 0-10 mm/hr ABO Type RH Type 0 256

05-20-08 98 30.6 15.9 65.9 28.4 0 0


								
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