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OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila Patient’s Name: UMALI, Russel Address: Lot 3 Block 8 Kahilom 3, Pandacan, Manila Age/Sex: 8 months/Male Date Admitted: June 6, 2008 Admitting Diagnosis: Acute gastroenteritis with severe signs of dehydration Physician–in-charge: Dr. Nunez/Arollado/Reyes Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez Hospital No. 1845122 24 HOUR HISTORY This is a case of an 8 month old boy who came in due to loose bowel movement. HISTORY OF PRESENT ILLNESS 1 day prior to admission, the patient had passage of loose, mostly watery stool, non-mucoid, non-bloody, non-foul smelling, approximately 10 bouts. This was associated with vomiting of previously ingested food. There was no fever, no cough or colds. No consult was done, no medications were given. A few hours prior to admission, there was persistence of symptoms. Patient was noted to have sunken eyeballs and decreased activity hence consult. PAST MEDICAL HISTORY Pre-natal/Birth/Postnatal: Mother had 9 pre-natal check-ups. She took ferrous sulfate. No maternal illness. Previous Hospitalizations: No history of previous hospitalization. Feeding History: bottle fed with Bonna 1:2 dilution from birth to 2 months and was shifted to condensed milk. 1 ounce in 7 ounces of water. Immunizations: (+) BCG, (+) Hepa B vaccine x 3 doses, (+) OPV x 3 doses, (+) DPT x 3 doses Growth and development: at par with age FAMILY HISTORY (+) Hypertension PERSONAL AND SOCIAL HISTORY: Drinking water is boiled for 30 minutes. PHYSICAL EXAMINATION: General: awake, irritable Vital Signs: HR = 134 RR = 80 Temp = 380C Wt: 9 kg SHEENT: normocephalic, sunken anterior fontanelle, sunken eyeball, anicteric sclera, pink palpebral conjunctiva, no cervical lymphadenopathy, nasoaural discharge Chest/Lungs: SCE, (+) subcostal retractions, clear breath sounds Cardiac: adynamic precordium, tachycardic, irregular rhythm, no murmur Abdomen: flat, NABS, soft, no tenderness Extremities: grossly normal extremities, full and equal pulses, no cyanosis, no edema ASSESSMENT: Acute gastroenteritis with sever signs of dehydration PLAN: For admission Patient was admitted to the Pediatric ward Room 421 under the service of Drs. C. Nunez/Arollado/Reyes. Patient was placed on DAT, IVF: D5 0.3 NaCl 580 mL x 5 hours to run at 116 cc/hour. Diagnostics: CBC with OC, fecalysis, Blood CS, CXR-AP/L. Therapeutics: Ampicillin 150 mg TIV q 6 hours, gentamicin 15 mg TIV q 12 hours, diazepam 1 mg TIV prn for seizure, paracetamol 1 mg/mL q 4 hours prn for fever. Input and output was monitored every 2 hours. Losses were replaced with PNSS. Vital signs were monitored every hour. On the 1st hospital day, patient was still on DAT with glucolyte intake. IVF: D5 0.3 NaCl 290 cc x 6 hours to run at 48 cc/hour. Hydrations was reassessed after 4 hours. Input and output was monitored. TSB if with fever. Vital signs were monitored every hour.
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