Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: Teologo, Ryzan Age/Sex: 2 years old/ M Address: 2258 Leveriza St. Malate, Manila Date Admitted: June 17, 2008 Admitting Diagnosis: Oral ulcer probably secondary to HSV with superimposed bacterial infection Physicians–in-charge: Dr. Nunez/Arollado/Reyes Clerks-in-charge: Fabian/Ilarde/Ingles/Item/Junsay
Hospital No. 1849099
48-hour History This is a case of a 2 year old male born on Dec. 23, 2005 and is currently residing at Leveriza St. Manila and was admitted for the 1 st time in this institution. Patient came in due to oral ulcer. HISTORY OF PRESENT ILLNESS 2 days PTA, patient noted to have oral lesion, flat, white in color, lower mid-lip in location, 3mm in diameter, noted to have mnimal amount of pus, consult was done at the OMMC-ER. Patient with occasional cough, patient was prescribed with Amoxicillin (40mkd) TID x 7 days and Xylogel ointment for mouth sores. 1 day PTA, patient mother noted that the oral lesions spread to the upper lip, oral desquamation was also noted. Patient had no intake of food for the day due to the painful lesion hence consult and subsequent admission at OMMC Pediatrics Ward. PAST MEDICAL HISTORY unremarkable PRENATAL/NATAL/POST NATAL Born full term to a G1P1 (1001) mother via NSD with no fetomaternal complications. Patient was breatfed since birth IMMUNIZATION BCG 1 dose OPV/DPT 3 dose Hep B 3 dose Measles 1 dose FAMILY HISTORY Denies hereditofamilial diseases PHYSICAL EXAMINATION: GENERAL SURVEY: awake,irritable, not in cardio-respiratory distress. VITAL SIGNS: HR =130 bpm RR= 70 cpm Temp= 37 °C wt= 10kg SHEENT: good skin turgor, good capillary refill, anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge, (-) CLAD (+) oral sores on both upper and lower lip, flat, whitish in color with minimal amount of pus and bleeding, (+) desquamation of both upper and lower lips. HEART; Adynamic precordium, normal rate regular rhythm, (-) murmur ABDOMEN: globular, NABS, soft, non tender EXTREMITIES: full and equal pulses, no edema, no cyanosis ASSESMENT: Oral ulcer probably secondary to HSV with superimposed bacterial infection PLAN: For admission Patient was admitted to Pedia Ward at 423 under the services of Dr.Nunez/Arollado/Reyes. NPO temporarily IVF: D5 0.3 NaCl 500cc to run at 54-55 cc/hr Laboratories: CBC c PC, Urinalysis, CXR APL Therapeutics: Acyclocir 200mg/5mL, 2.5 mL TID x 7 days, Pen G 500,000 u/SVP q6 (200mkd), Paracetamol 100mg/IV q4 for pain and fever Monitor vsq4 COURSE IN THE WARDS On the 1st hospital day, patient has an oral lesion, has cough, clear breath sounds, symmetric chest expansion, no retractions, HR105, RR24, T38.0C. patient may have soft diet, IV-TF: D5.3NaCl 500cc to run at 54-55cc/hr (FM=30%) Continue medications, continue TSB for fever, follow-up labs VSq2. On the 2nd hospital day, CR150, RR48, T39.1C, (+) cough, (-) alar flaring, (+) oral lesions, Clear breath sounds, (-) retractions, full equal pulses. Patient was continued on feeding with SAP, IVF-TF D50.3 NaCl 500cc to run at 54-55cc/hr, continue meds, follow-up other labs, VSQ2.