Dazo_ KM-PDS by dredwardmark



Name: DAZO, KIM MICHAEL Age/Sex: 12 y/o/M Address: Malate, Manila Date of Admission: May 24, 2008 Admitting Diagnosis: UTI T/C Typhoid Fever Residents-in-charge:Dr. Troncales/ Dr. Salloman/ Dr. Manalo Clerks-in-charge: Erum/ Fernando/ Figueras/ Fuentes/ Cuvin

Hospital No. 1839211

PATIENT DISCHARGE SUMMARY This is a case of a 12-year old male from 2258 Internal 2B Leveriza St., Malate, Manila who came in due to diarrhea & vomiting. History of Present Illness: Patient was apparently well until.. 3 days PTA, patient developed fever, undocumented. No cough, no colds, took Paracetamol 500mg/tab, ½ tab which offered temporary relief. No consult done. 2 days PTA, patient had an on and off fever, with loose watery nonmucoid stool, 3 bouts with vomiting of previously ingested food. Paracetamol was continued, with no relief of symptoms. Few Hours PTA, there was persistence of diarrhea, vomiting and fever. This prompted consult, hence admission. Review of Systems: (-) seizures (-) cyanosis (-) dyspnea (-) weight loss (-) orthopnea

(-) headache (-) body weakness (-) blurring of vision (-) palpitation (-) easy fatigability

Past Medical History: (-) hospitalization, allergies (-) bronchial asthma, (-) PTB Family History: Denies any heredofamilial disease Social/ Environmental: Nonalcoholic beverage drinker, nonsmoker PHYSICAL EXAM General survey: The patient is alert, coherent and not in respiratory distress. Vital Signs: BP=90/60 T=37.4 C HR= 100 bpm RR=20 cpm Weight: 35kg SHEENT: pink palpebral conjunctiva, (-) alar flaring, anicteric sclera, (-) CLAD Chest:: Lungs- symmetrical chest expansion, (-) subcostal retractions, clear breath sounds Heart: adynamic precordium, normal cardiac rate and regular rhytm, (-)murmur Abdomen: flat, soft, normoactive bowel sounds, no palpable mass Genitalia: grossly normal findings Extremities: full pulses, no cyanosis ASSESSEMENT: UTI T/C Typhoid Fever

PLAN: For admission Patient was admitted at Pediatrics ward (Infirmary) under the service of Drs. Troncales/ Salloman / Manalo. Patient had soft diet as tolerated. Laboratory exams requested were: CBC PC, BT, Blood CS, serum Na, K, Typhidot, PTT, PT. IVF: D5NM 1L at rate 75 ugtts/min. May replace vomiting/fecal losses with equal amount of PNSS. May give Paracetamol 500mg/tab 1tab q4 if T> 37.8C. May start Co-trimoxazole 400mg/tab 1 tab BID. IVF was revised to D5IMB 1 L + 40meqs KCL x 12 hours to run at 83-84 ugtts/min x 2 doses (FM, RR 0.15meqs/kg/hr). For PFA & CXR once available. Started: Ranitidine 35mg TIV q8, Ampicillin 500mg TIV q6 (-) ANST. Cotrimoxazole was hold. Paracetamol PO was shifted TIV 1 ampule q4 for T> 37.8C, TSB. On the 1st hospital day, diet is maintained. IVF: D5 0.3 NaCl 1L (32gtts/min) to run for 8 hours. Medications were still continued. Still for CXR and PFA once available. Vital signs monitored every 4 hours. On the 2nd hospital day, diet is maintained. IVF: D5IMB 1l + 40 meqs KCl for 12 hours (2 doses). Medications were still continued. Still for CXR and PFA once available. Vital signs monitored every 4 hours. On the 3rd hospital day, diet and IVF was still maintained. Following laboratories were done: CBC with PC, blood CS, repeat Na, K. Medications given are Ampicillin 500 mg TIV q6 and Ranitidine 35 g TIV q6. May give ParacetamolTIV 1 ampule for T> 37.8C. For PFA and CXR once available. Vital signs monitored every 4 hours. On the 4th hospital day,

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