OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila
Patient’s Name: Awitan, Renalyn Address: 1130 Pasaje Del Carmen Quiapo, Manila Age/Sex: 2 ½ /F Date Admitted: May 30, 2008 Admitting Diagnosis: CNS Infection (TB Meningitis vs Bacterial) Physician–in-charge: Dr. Nunez/Arollado/Reyes Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 1841722
CLINICAL ABSTRACT This is a case of a 2 ½ /F who came in due to stiffening of the right upper and lower extremity. HISTORY OF PRESENT ILLNESS 1 month PTA, patient had productive cough with whitish sputum, no colds, no fever. No medications given nor consult was done. 1 week PTA, patient had productive cough of yellowish sputum, no colds. There was also noted foul smelling discharge at the right ear. Patient was febrile however grade was undocumented. No vomiting, no loose bowel movement. Patient was noticed to have poor suck, poor urine output. Patient was given Paracetamol every 4 hours which temporarily gave relief. No consult was done. 1 day PTA, above signs and symptoms persisted and this time it is accompanied with vomiting of two times however informant cannot approximate the amount of vomitus. Few hours PTA, there was stiffening of the right upper and lower extremity with associated deviation of the eyeballs to the left which occurred for 5 times. There was noted cyanosis of the nail beds. This prompted consult at the OMMC Pedia-ER which is subsequently admitted. PAST MEDICAL HISTORY Previous Hospitalizations: No history of previous hospitalization. Pre-natal/Birth: Patient was born to a 20 y/o G2P2 (2-0-0-2) mother. Other informations was unknown to the informant. Feeding History: Not known to the informant Immunizations: Not known to the informant FAMILY HISTORY (+) TB exposure - mother (-) DM (-) bronchial asthma PERSONAL AND SOCIAL HISTORY: Development at par with age. Lives in a congested area. PHYSICAL EXAMINATION: General: Lethargic, carried by informant, NICRD Vital Signs: HR = 90/50 (left arm) RR = 24 CR: 106 Temp = 370C Wt: 9 kg SHEENT: anicteric sclera, pink palpebral conjunctiva, no no cervical lymphadenopathy, nasoaural discharge Chest/Lungs: SCE, (-) retractions, harsh breath sounds Cardiac: adynamic precordium, normal rate, irregular rhythm, no murmur Abdomen: flat, NABS, soft, no tenderness Extremities: grossly normal extremities, full and equal pulses, no cyanosis, no edema Neuro: lethargic, irritable CN I – N/A CN II – 2-3 mm, equally reactive CN III, IV,VI – can move eyes side to side CN VII – (+) facial asymmetry CN IX, X – good gag CN XII – tongue is midline CN XI – can turn face side to side ASSESSMENT: CNS Infection (TB Meningitis vs Bacterial) PLAN: For admission
Patient was admitted under the service of Drs. Troncales/Salloman/Manalo. May have milk feeding once patient is fully awake. IVF is D5IMB 1L 675 ml to run for 28-29 ugtts/min. O2 support at 2-3 lpm via nasal cannula. Diagnostic test requested were: CBC with PC, Na, K, 15 L ECG, CXR AP/L, UA, CSF analysis and Blood CS. Medications given are Penicillin G 500,000 ‘u’ q6 TIV after negative skin test, Chloramphenicol 300 mg q8 TIV after negative skin test, Isoniazid 200 mg/5ml, 2ml OD, Rifampicin 200 mg/5ml, 3 ml OD, Pyrazinamide 250 mg/5ml, 5 ml OD and Diazepam 2 mg prn for frank seizure. Started with Phenobarbital 90mg TIV then 45 mg q8 and Mannitol 2.25g to run for 30 minutes.