Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: Delfin, Raymond Age/Sex: 17 days/M Address: FB Harrison Pasay City Date Admitted: June 2, 2008 Admitting Diagnosis: Acute Gastroenteritis with moderate dehydration t/c Neonatorium, late onset Physicians–in-charge: Dr. Nunez/Arollado/Reyes Clerks-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 1843240
48 HOUR HISTORY This is a case of a 17 days old baby boy brought in due to loose stool and poor feeding. Patient was born preterm to a 19 year old G1P1 (0101) via NSD at Amang Rodriguez Hospital. No fetomaternal complication but stayed at hospital for 5 days for observation (club foot). Good suck, cry, and activity. Patient was apparently well until… HISTORY OF PRESENT ILLNESS 3 days PTA, patient had cough associated with 4x watery diarrhea with particles, yellowish, non mucoidal, non foul smelling, non bloody. No vomiting, no fever, no consult, no medications given. 2 days PTA, patient still had loose bowel stool 3x with the same consistency. Still no consult. 1 day PTA, persistence of the above condition with associated fever (undocumented) consult at NCH and was sent home with home medications of the following: Ampicillin (36 mkd) 2 doses with relief. Few hours PTA, patient still had loose stool 4x with associated difficulty of breathing while coughing. Hence, consult at OMMC Department of Pediatrics. PRENATAL/NATAL/POST NATAL HISTORY Mother of patient claimed having 4 pre-natal check ups at a local heath center. Patient had taken Ferrous sulfate, Multivitamin during the course of her pregnancy. Patient however is positive for Hepatitis B and had UTI at 7 months AOG and was treated with Amoxicillin for 7 days. No fetomaternal complication (clubfoot was noted). No Hepatitis B IgG was given. FAMILY MEDICAL HISTORY Patient has family history of asthma (maternal), hypertension (maternal), no PTB. IMMUNIZATION (+) BCG, 1 dose of Hepa B vaccine FEEDING Intermittent breast feeding; Bona milk 1:2 dil PHYSICAL EXAMINATION: GENERAL SURVEY: awake, fair cry and activity VITAL SIGNS: HR =140 bpm RR= 66 cpm Temp= 37.1 °C ANTHROPOMETRICS: HC = 33 cm CC = 32 cm AC = 31 cm SHEENT: skin tenting, sunken fontanel, sunken eyeballs CHEST: symmetrical chest expansion, with minimal retractions, clear breath sounds HEART; Adynamic precordium, normal rate regular rhythm, (-) murmur ABDOMEN: globular,NABS, soft, non tender EXTREMITIES: grossly normal extremities, full and equal pulses ASSESMENT: Acute Gastroenteritis with moderate dehydration t/c Sepsis Neonatorium, late onset PLAN: For admission Patient was admitted to Pedia Ward at Rm 420 under the services of Dr.Nunez/Arollado/Reyes. Vital signs monitoring was done q1. Patient was placed on NPO temporarily with monitoring of Hgt every 8 hours. Patient was maintained on D5IMB 325 cc x 24 hours at 13-14 cc/hr. Laboratories requested are: CBC with PC, Blood CS, urinalysis, fecalysis, CXR – APL, serum Na and K. Medications are: Ampicillin 100 mg SVIP Q8 HOURS (120 mkD), Gentamicin 12 mg SVIP q24 hours. O2 support via funnel at 4-5 lpm. Patient was monitored for frequency and consistency of stool and recorded. Diaper pre and post soiling was weighed. Patient was given DLRS 50cc IV bolus and NaHCO3 5 meqs + equal amount of distilled water slow IV push. COURSE IN THE WARDS: On the 1st hospital day, patient was started on milk feeding/cup 2 cc q 3 hours, to increase by 1 cc if tolerated, with SAP and burping. O2 support was shifted tofunnel at 3-4 lpm. PNSS 12.5 cc was pushed as IV bolus. Patient was given sodium bicarbonate 2.5 meq + equal amount of water SIVP. IVF TF: D5 W 315 mL + NaCl 2 mL + KCl 2.5 mL + Calcium gluconate 5 mL for a total of 325 mL to run for 24 hours at a rate of 13-14 ugtts.min. Hydration was reassessed after 4 hours. Medications were continued. Patient was still for LP. Repeat Na+ and K+ was done. Input and output was monitored every shift. Vital signs were monitored every hour. On the 2nd hospital day, patient was transferred to Room 420. Milk feeding was increased to 10 cc q 3 hours, to increase by 2 cc every feeding until 30 cc was reached. O2 support was continued. Medications were continued. IVF TF: D5W 265.5 mL + NaCl 2 mL + KCl 2.5 mL + calcium gluconate 5 cc for a total of 275 mL to run at 5 ugtts/min. Vital signs were monitored every 2 hours.