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					OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics NAME: FLORES, CLARK IVAN Hospital Number: 1837024 AGE/SEX: 1month / Male ADDRESS: 2460 Oro B Street, Sta. Ana, Manila DATEOF ADMISSION: May 17, 2008 ADMITTING DIAGNOSIS: Pneumonia, severe Congenital heart disease t/c Ventricular septal defect PHYSICIANS-IN-CHARGE: Dr. Troncales/Dr. Salloman/Dr. Manalo CLERKS-IN-CHARGE: Cuvin/Erum/Fernando/Figueras/Fuentes Florentino/Kalalo/Lingao/Liwag/Lopez PATIENT DISCHARGE SUMMARY Informant: mother % Reliability: 90% Chief Complaint: difficulty of breathing This is a case of a 1-month-3-week-old patient who was brought in due to difficulty of breathing. HISTORY OF PRESENT ILLNESS: 3 weeks prior to admission, the patient dry non-productive cough with no associated watery nasal discharge, no fever, and no seizures. The patient had episodes of cyanosis upon incessant crying. 2 weeks prior to admission, the patient consulted with a local heart center due to cough and was given salbutamol and ambroxol which gave temporary relief of symptoms. 1 day prior to admission, the patient had persistence of cough and episodes of cyanosis which prompted consult and subsequent admission. REVIEW OF SYSTEMS: PAST MEDICAL HISTORY: Pre-natal: The patient’s mother had no illness or diseases during pregnancy and took multivitamins. Birth: born full term to a G1P1 (1-0-0-1) mother via NSD at PGH. Post-natal: No noted complications after delivery. Feeding: the patient is breastfed up to present. Growth and Development: Patient is at par with age Previous hospitalizations: none Immunization: (+) BCG, 1 dose (-) DPT (-) OPV, (+) Hepa B, 1 dose (-) MMR Developmental: can do social smile FAMILY HISTORY: (-) asthma (-) cardiovascular disease (-) DM (-) renal disease (-) cancer (-) allergies (-) PTB PERSONAL AND SOCIAL HISTORY: The patient is usually lying and sleeps a lot. PHYSICAL EXAMINATION: General: awake, alert in mild cardiorespiratory distress. Vital Signs: HR = 120 RR = 55 cpm Temp = 36.50 C Skin: no jaundice, no skin tenting

HEENT: Head: no scars, no tenderness Eyes: Anicteric sclera, pink palpebral conjunctiva Ears: no discharge Nose: no alar flaring, (+) mucoid nasal discharge Mouth/Throat: (+) tonsillopharyngeal congestion, moist lips and mucus membrane, no Neck: (+) CLAD
ulcerations

Chest/Lungs: Symmetric chest expansion, minimal subcostal retraction, harsh breath Heart: adynamic precordium, normal rate and regular rhythm, (+) holosystolic murmur 2/6 on the lower
parasternal border with no radiation Abdomen: non-distended, normoactive bowel sounds, soft, non-tender Extremities: grossly normal, no edema, no cyanosis, weak pulses ASSESSMENT: Pneumonia, severe Congenital heart disease t/c Ventricular septal defect PLAN: for admission The patient was placed on NPO temporarily. D5IMB 500cc was given to run at 22-23 ugtts/min. The patient was started on ampicillin 110mg IV every 12 hours (100mkday), gentamycin 11mg IV every 12 hour (5mkday), and salbutamol nebulization every 2 hours. The patient was requested for CBC with PC, blood typing, chest x-ray AP and lateral, ECG 15lead, and Blood culture and sensitivity. Input and output was monitored. Vital signs were monitored every 2 hours. COURSE IN THE WARDS: 17 On the 1st hospital day, NPO was maintained. IV fluid was continued. Medications were continued. Salbutamol nebulization every 2 hours was started. High back rest was maintained. Vital signs were monitored every hour. 18 On the 2nd hospital day, milk feeding was continued with strict aspiration precaution. IV fluid was maintained. Medications were continued as well as salbutamol nebulisation but was reduced to every 4 hours. Hydrocortisone was also started 35 mg starting dose then 20mg every 6 hours. The patient was still for blood CS. Vital signs were monitored every 2 hours. 19 On the 3rd hospital day, diet was maintained. IV fluid was consumed and was shifted to heplock. Medications were continued but salbutamol nebulization was reduced to every 6 hours. The patent was requested for blood CS. Vital signs were monitored every 4 hours. 20 On the 4th hospital day, diet was maintained. Heplock was maintained. IV medications were continued. Vital signs were monitored every 4 hours. 21 On the 5th hospital day, diet was maintained. IV fluid was consumed and was shifted to heplock. Medications were continued but salbutamol nebulization was reduced to every 8 hours. X-ray plates were to be retrieved and placed at bedside. A repeat 15LECG was requested. IV medications were continued. Vital signs were monitored every 4 hours. 22 On the 6th hospital day, diet was maintained with strict aspiration precaution. The patient is for referral to a cardiology consultant. IV medications were continued. Vital signs were monitored every 4 hours. 23 On the 7th hospital day, diet was shifted to AL110. The patient had repeated bouts of soft stool so the patient was placed on mild hydration and was given D5 0.3 NaCl 215 cc to run for 6 hours at the rate of 35-36 cc/hr. IV medications were continued except for hydrocortisone which was discontinued. Vital signs were monitored every 4 hours. 24 On the 8th hospital day, diet was maintained with strict aspiration precaution. IV fluid was revised to D5 0.3 NaCl 500 cc to run for 6 hours at the rate of 22-23 cc/hr. The patient was started on piperacillin-tazobactam 200mg SLP every 12 hours, and amikacin 60mg SLP every 24 hours. Ampicillin and gentamycin was discontinued once piperacillin-tazobactam and amikacin were available. Vitamin A 50,000 IU PO was given single dose. Immunosine was started 2ml once a day. The patient was requested for fecalysis and blood CS. Vital signs were monitored every 2 hours watching out for frequency and consistency of stool. 25 On the 9th hospital day, diet was maintained with strict aspiration precaution. D5IMB 500cc at 18 cc/hr was given. Medications were continued. Vital signs were monitored every 2 hours watching out for frequency and consistency of stool. On the 10th hospital day, milk feeding with Al 110 was continued. IVF was decreased to 13-14 cc/hour. IV medications were continued. Frequency and consistency of stools were monitored. Vital signs were monitored every 2 hours. On the 11th hospital day, IVF was discontinued and was shifted to heplock. IV medications were continued. On the 12th hospital day, ORS was given as tolerated with strict aspiration precaution. Salbutamol nebulisation was discontinued. Frequency and consistency of stools were monitored. Vital signs were monitored every 2 hours. SUMMARY OF LABORATORY RESULTS: FECALYSIS: (5/24) Color: yellow Consistency: oft Pus: 0-1/hpf RBC: none Ova: none Fat globules: few Sounds all lung field

COMPLETE BLOOD CELL COUNT WITH PLATELET COUNT Normal Values May 16 WBC RBC HGB PLATELET NEUTROP LYMPHO MONO EOSINO 8.0-38.0 X 109/L 4.6-6.6 X 1012/L 150-220 g/L 150-400 X 109/L 0.23-0.77 0.25-0.36 0.02-0.09 0.00-0.04 125 211 23 84 03 8.2


				
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