CARDILLO_ CRISTINA pds by dredwardmark


									Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila

Patient’s Name: CARDILLO, Cristina Address: 2060 Batangas Line, Paco Manila Age/Sex: 1 mo/F Date Admitted: May 26, 2008 Admitting Diagnosis: Neonatal pneumonia, r/o Sepsis Physician–in-charge: Dr. Troncales/Salloman/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez

Hospital No. 1839783

PATIENT DISCHARGE SUMMARY This is a case of a 1 month-old female born full-term to a 22 y/o G1P1 (1-0-0-1) via NSD who came in due to cough. HISTORY OF PRESENT ILLNESS 3 days prior to admission, patient started to have colds and nasal congestion. No medication given. No consult was done. 2 days prior to admission, there is persistence of cough and noted bluing of face every time the patient coughs. Patient still has good suck. Few hours prior to admission, persistence of above condition prompted consult at the OMMC-Pedia ER. PAST MEDICAL HISTORY: Pre-natal/Birth: Patient is a first born child, born full-term to a 22 y/o G1P1 (1-0-0-1) via NSD, with no fetomaternal complications at JRMMC. Mother had only 4 prenatal check ups starting at 7 months AOG. On the 7th month AOG mother was diagnosed to have UTI and was given unrecalled medications. Feeding and Nutrition: mixed fed with breastmilk and Bonna since birth at 1:2 dilution. Immunization: (+) BCG x 1 dose, Hepa B x 1 dose FAMILY HISTORY/ PERSONAL AND SOCIAL HISTORY: (-) PTB, (+) asthma – aunt on father’s side The patient’s mother denies any family history of diabetes mellitus, cardiac disease PHYSICAL EXAMINATION: General: awake, active, not in cardiorespiratory distress Vital Signs: HR = 128 RR = 56 Temp = 37.3 0C Weight = 3.4 kg SHEENT: flat anterior fontanel, anicteric sclera, pink palpebral conjunctiva, (-) CLAD, (-) neck mass Chest/Lungs: SCE, (+) occasional retractions, (+) harsh breath sounds Cardiac: adynamic precordium, NRRR, no murmur Abdomen: globular, NABS, soft, nontender Extremities: grossly normal extremities, full pulses, no cyanosis, no edema ASSESSMENT: Neonatal Pneumonia, r/o Sepsis PLAN: For admission

Patient was admitted at the Pedia wards under the service of Drs. Troncales/Salloman/Manalo. Patient was placed on NPO temporarily and was hooked to D5IMB 500cc to run at a rate of 14-15 ugtts/min. Diagnostics requested were CBC with PC, BT, CXR APL, Blood CS. Medication given were: Ampicillin 125 mg IV q6, Gentamycin 17 mg IV q 24 and Salbutamol nebulization ½ neb + 2 cc NSS every 6 hours. Vital signs were monitored every hour. On the 2nd hospital day patient was resumed with MF with SAP and was still hooked to D5IMB 500cc to run at a rate of 14-15 ugtts/min.Salbutamol nebulization was maintained every 6 hours. IV meds are Ampicillin Ampicillin 125 mg IV q6 and Gentamycin 17 mg IV q 24. Nasal secretions suctioned every 6 hours. Vital signs monitored every 2 hours. On the 3rd hospital day, milk feeding or breastfeeding with strict aspiration precaution was continued. Salbutamol nebulization was done very 6 hours. Nasal secretions were suctioned as needed. IV medications were continued. IVF was decreased to 10-11 cc/hour. Vital signs were monitored every 4 hours.

SUMMARY OF LABORATORY RESULTS COMPLETE BLOOD CELL COUNT WITH PLATELET COUNT Normal Values May 25 WBC 8.0-38.0 X 109/L 14.9 RBC 4.6-6.6 X 1012/L 3.25 HGB 150-220 g/L 11.3 HCT 40 – 54 % 31.7 PLATELET 150-400 X 109/L 393 NEUTROP 0.23-0.77 24.1 LYMPHO 0.25-0.36 71.1 MONO 0.02-0.09 3.7 EOSINO 0.00-0.04 0.7

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