OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila
Patient’s Name: Cabo, Yuan Lea Address: 2317 DPWH Compound, Punta, Sta. Ana Manila Age/Sex: 2 mo/M Date Admitted: May 25, 2008 Admitting Diagnosis: Pneumonia, Severe Physician–in-charge: Dr. Troncales/Salloman/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
CLINICAL ABSTRACT This is a case of a 2 month-old male born full-term to a 24 y/o G1P1 (1-0-0-1) via NSD who came in due to difficulty of breathing. HISTORY OF PRESENT ILLNESS Three weeks PTA, patient had productive cough (whitish yellowish) with associated colds (whitish yellowish nasal discharge) noted. No fever, DOB, loss of appetite or changes in bowel movement. Consult was done at a private clinic where he was prescribed with carbocisteine 0.3ml TID. Mother noted relief of cough and colds for 1 week. One week PTA, productive cough and colds with the same character as before recurred. Patient also had undocumented fever and one bout of vomiting of previously ingested milk. They consulted another private clinic where they were prescribed with Terbutaline drops (0.06mkd). No relief was noted. Three days PTA, symptoms still persisted with associated vomiting and diarrhea. Few hours PTA, patient had difficulty of breathing (described by his mother as “fast breathing”). There was no note of cyanosis. This prompted consult at the OMMC-Pedia ER where the patient was subsequently admitted. PAST MEDICAL HISTORY Patient was born to a 28 yo G1P1 mother via NSD, with no fetomaternal complications. Immunizations: (+) BCG x 2 doses, (+) DPT x 2 doses, (+) Hep B x 2 doses No previous hospitalizations. FAMILY HISTORY The patient’s mother denies any family history of asthma, diabetes mellitus, cardiac disease or respiratory diseases. PERSONAL AND SOCIAL HISTORY: Patient is a cheerful child. Development at par with age. Patient lives with in a congested household with 7 other relatives. Patient’s mother has had cough for a month. The house has 2 windows, with 1 pour-flushed bathroom. Drinking water is boiled from NAWASA. Garbage is collected daily. PHYSICAL EXAMINATION: General: Asleep, comfortable, in mild respiratory distress Vital Signs: HR = 120s RR = 66 Temp = 37.90C Wt: 11.3 kg Anthropometrics: Weight = 4.3kg Length= 51cm HC= 37cm AC= 33cm CC=37cm SHEENT: good skin turgor, anterior fontanel not depressed, anicteric sclera, pink palpebral conjunctiva, no no cervical lymphadenopathy, nasoaural discharge Chest/Lungs: SCE, (+) chest indrawing, (+) subcostal retractions (+) crackles both all lung fields Cardiac: adynamic precordium, NRRR, no murmur Abdomen: globular, NABS, soft, no tenderness Extremities: grossly normal extremities, full pulses, no cyanosis, no edema ASSESSMENT:
Pneumonia, Severe PLAN: For admission
Patient was admitted at the Pedia Ward Rm. 420 under the service of Drs. Troncales/Salloman/Manalo. Laboratories requested were CBC PC, CXR APL and Blood CS. Patient’s diet was anything tolerated with SAP but was placed on temporary NPO with HGT monitoring q12. IVF: D50.3 NaCl 500cc to run at a rate of 21-22µgtts/hour. May have O2 support via cannula at 2-3 lpm. Medications started were: Ampicillin 150 mg SIVP q8 (105 mkd) and Gentamycin 11mg q12 (5mkd). WOF: respiratory distress like increase in RR, cyanosis, deepening of retractions.