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

Patient’s Name: Lerios, Brigitte Hospital No. 1839444 Address: Manila Room no. 418 Age/Sex: 8 months/ F Date Admitted: May 24, 2008 Admitting Diagnosis: Angioedema 2° to hypersensitivity reaction probably 2° to ingestants Physician–in-charge: Dr. Troncales/ Dr. Salloman/Dr. Manalo Clerk-in-charge: Erum/Fernando/Figueras/Fuentes/Cuvin

PATIENT DISCHARGE SUMMARY This is a case of an 8 month old baby girl born to a G6P6 (6-0-0-6) mother via NSD who came in due to redness of the whole body. HISTORY OF PRESENT ILLNESS Present condition started 2 days prior to consult when patient had skin rash, consulted at Pedia-ER and was given diphenhydramine TIV and Citirizine drops as home meds. 1 day PTC, there was persistence of rash and itchiness. Medications were continued. No consult done. Few hours PTC, there was persistence of rash, discoloration on the soles and palms hence consulted at Pedia-ER. REVIEW OF SYSTEMS: N/A PAST MEDICAL HISTORY: Pre-natal: the mother had a regular prenatal check-up. There were no maternal illnesses during pregnancy. No medications with teratogenic effects were taken during her pregnancy. Birth: born full term to a 29 year-old G6P6 mother via NSD at OMMC without any complications. Post-natal: patient was breastfed from birth up to 6 months and was then shifted to milk feeding. Immunization: BCG, 3 Hepa B, 3 DPT, 3 OPV FAMILY HISTORY/ PERSONAL AND SOCIAL HISTORY: (+) asthma-mother side (+) HPN-father side PHYSICAL EXAMINATION: General: awake, not in cardiorespiratory distress Vital Signs: 0 HR = 130 RR = 40 Temp = 37.3 C Weight = 8.5 kg SHEENT: (+) redness of the whole body, anicteric sclera, pink palpebral conjunctiva, no cervical lymphadenopathy Chest/Lungs: symmetric chest expansion, no retractions, clear breath sounds Heart: adynamic precordium, normal rate and regular rhythm, no murmurs Abdomen: flabby, soft, distended abdomen, normoactive bowel sounds, no tenderness Extremities: full and equal pulses ASSESSMENT: Angioedema 2° to hypersensitivity reaction probably 2° to ingestants PLAN: For admission Course in the Wards: st On the 1 HD, patient was on a hypoallergenic diet.IVF: D5 IMB 637mlx24hrs to run at a rate of 26-27cc/hr. Medications given were hydrocortisone 34mg every 6 hours, diphenhydramine 10mg every 8 hours, Vital signs monitored every 2 hours. nd On the 2 HD, diet was continued. IVF: D5 IMB 500cc x 26-27ugtts/hr. medications were continued. VSq2. Patient was advised o go home with the following medications: Cetirizine 2.5mg/ml, Prednisone 10mg/5ml, 2.5ml q12 x 5 more days, Amoxicillin 100mg/ml, 1 ml q8 x 7 days. Patient was advised to repeat UA on day 3 of Amoxicillin. And was advised for follow-up on May 31, 2008

LABORATORY SUMMARY CBC/PC 05/23 RBC 3.87 Hgb 9.9 Hct 28.5 MCV 73.7 MCH 25.6 MCHC 34.8 WBC 21.4 Neu 27.8 Lym 64.7 Mo 7.0 Eos 0.5 Ba 0.0


				
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