Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila Patient’s Name: Dayanan, April Jane Age/Sex: 1 month old/F Address: Estero Dela Reina Binondo Manila Date Admitted: May 29, 2008 Admitting Diagnosis: Acute Gastroenteritis with moderate signs of dehydration Physicians–in-charge: Dr. Troncales/Dr. Salloman/Dr. Manalo Clerks-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez CLINICAL ABSTRACT Hospital No. 1841404 HISTORY OF PRESENT ILLNESS This is a case of a 1 month old female born to a 22 year old G1P1 (1001) mother via NSD at LHC without any complications. Patient had good suck, good activity, with episodes of cyanosis upon crying and interrupted feeding. 2 days PTA, patient had 4 episodes of vomiting with loose watery stools characterized by yellowish, mucoid, non bloody stool. No associated fever, and with good suck. Few hours PTA, with persistence of vomiting and loose watery stools associated with poor suck, patient was then brought to OMMC for consult and was subsequently admitted. REVIEW OF SYSTEMS: (+) cyanotic episodes upon crying (+) episodes of tachypnea (+) interrupted feeding PAST MEDICAL HISTORY 1. BIRTH HISTORY Patient was born to a 22 year old G1P1 (1001) mother via NSD at LHC without any complications. Mother claims to have had regular prenatal check up and denies illness during the course of pregnancy. 2. PAST MEDICAL HISTORY: No previous hospitalizations or check ups. 3. FAMILY HISTORY Informant denies any familial hereditary diseases 4. IMMUNIZATION No vaccination 5. FEEDING HISTORY Patient was given Bonamil 1:2 feeding PHYSICAL EXAMINATION: GENERAL SURVEY: awake, irritable VITAL SIGNS: HR =120 bpm RR= 48 cpm Temp= 36.7 C WEIGHT: 2.9 kg SHEENT: sunken fontanelle, dry oral mucosa CHEST: Symmetrical chest expansion,clear breath sounds, no adventitious sounds HEART; Adynamic precordium,normal rate regular rhythm, Grade 2/6 holosystolic murmur Right parasternal border ABDOMEN: distended abdomen,hypoactive bowel sound, non palpable mass, liver edge 2cm SCM GUT: no gross genitourinary deformity EXTREMITIES: grossly normal extremities, full equal pulses, dusky nail beds ASSESMENT: Acute Gastroenteritis with moderate dehydration Sepsis T/C CHD, Cyanotic T/C PS PLAN: For admission Patient was admitted to Pedia PICU under the service of Dr. Troncales/Sollaman/Manalo. Patient was monitored VSq2. I and O recorded. Patient was maintained on NPO. Laboratories requested are the following: CBC with PC, BT, UA, FA, Na, K, PFA, 15 lead ECG, Blood CS. Patient was started on IVF D5 IMB 500 cc at a rate of 15 ugtts/min. patient was started on Ampicillin 150 mg IV q6 (200 mkd), Gentamycin 7.5 mg IV q12 (5 mkd), Metronidazole 50 mg IV q8 ( 50 mkd). Patient was replaced fecal vomiting loss with equal amount of PNSS. Patient was kept thermoregulated at all times.
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