Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: Sibug, Brian Kyle Address: 138 Patria St. Balot, Tondo, Manila Age/Sex: 9 mo./male Date Admitted: June 3, 2008 Admitting Diagnosis: Bronchiolitis Physician–in-charge: Dr.Nunez/ Arollado/Reyes Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 1799560
CLINICAL ABSTRACT This is a case of a 9 month-old male, born on Sept. 10, 2007 from Tondo, Manila, who was brought in due to difficulty of breathing. HISTORY OF PRESENT ILLNESS 2 days PTA, patient had colds with yellowish to greenish nasal discharge. No associated cough, fever, vomiting, noted. Self-medicated with Disudrin drops 0.75ml TID and afforded no relief. No consult was done. 1 day PTA, persistence of colds but now with associated cough and difficulty of breathing. No associated fever and vomiting noted. Selfmedicated with Amoxicillin drops 1ml q8 and Solmux drops 1ml q8. No consult was done. Few hours PTA, persistence of above symptoms and increased severity of difficulty of breathing prompted consult. PAST MEDICAL HISTORY No previous hospitalization IMMUNIZATION HISTORY 1 dose of BCG, 3 doses of OPV, 3 doses of DPT, 3 doses of Hepa B, (-) measles FAMILY HISTORY (+) asthma – maternal side (+) exposure to cigarette smoking PRENATAL/POSTNATAL HISTORY Patient was born in a lying-in center, full term, was not breastfed and was adopted by another family. He was given formula milk Bona and Nestogen 2. DEVELOPMENTAL HISTORY At par with age. PHYSICAL EXAMINATION: General: awake, irritable, NICRD Vital Signs: HR = 130 RR = 54 Temp = 37.70C Wt: 7.3 kg SHEENT: good skin turgor, anicteric sclera, pink palpebral conjunctiva, no tonsillopharyngeal congestion, (+) cervical lymphadenopathy, no nosoaural discharge Chest/Lungs: SCE, (+) subcostal retractions, (+) wheezes on all lung fields Cardiac: adynamic precordium, NRRR, no murmur Abdomen: flat, NABS, soft, no tenderness Extremities: grossly normal extremities, full equal pulses, (-) edema, (-) cyanosis ASSESSMENT: Bronchiolitis PLAN: For admission
Patient was admitted at Pedia ward rm. 422 under the service of Drs. Nunez/Arollado/Reyes. Patient was advised mixed feedingwith strict aspiration precaution. IVF given was D5 IMB 500ml to run for 6 hours at 30-31 cc/hr. Laboratories requested were CBC/PC, CXR-APL, and Blood CS. Medications started were: Ampicillin 250mg TIV ANST SIVP q6,Paracetamol 100mg/ml 1ml q4 PRN for Temp>37.8. Salbutamol nebule ½ nebule + 2cc PNSS q4, and Hydrocortisone 50mg TIV now, then 30mg TIV q6. VSq2.