Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: Perez, April S. Age/Sex: 8 year old/Female Address: 11th Street Port Area, Manila Date Admitted: June 3, 2008 Admitting Diagnosis: Cellulitis Left Leg Physicians–in-charge: Dr. Nunez/Arollado/Reyes Clerks-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 1843488
CLINICAL ABSTRACT This is a case of an 8 year old female who was brought in the OMMC Pediatrics ER due to loose water stool) Patient was apparently well until… HISTORY OF PRESENT ILLNESS 2 days PTA, patient had a lacerated wound at anterior surface the left leg, no swelling, no fever. 1 day PTA, patient had pus at the wound (+) possible manipulation of wound swelling. Patient had already fever. Patient was given medication with Paracetamol with temporary relief from fever; and Cloxacillin (61 mkd). Few hours PTA, the persistence of symptoms prompted consult and subsequent admission in OMMC Department of Pediatrics. REVIEW OF SYMPTOMS SHEENT: (+) wound healed (1 week PTA), no headache, no dizziness, no dysphagia CHEST/LUNGS: no cough, no colds, no difficulty of breathing CVS: no chest pain, no easy fatigability, no palpitations ABDOMEN: no abdominal pain, no nausea, no vomiting, no constipation, no diarrhea GUT: no dysuria, no nocturia, no frequency EXTREMITIES: no muscle pain, no joint pain NEURO: no loss of consciousness, no seizure PAST MEDICAL HISTORY No history of previous hospitalization, no bronchial asthma, no history of primary complex FAMILY MEDICAL HISTORY Patient has no family history of asthma, and denies any family member to have PTB. PERSONAL/SOCIAL HISTORY Patient lives in a congested environment together with parents, 2 siblings, and 2 relatives. Patient is incoming Grade 2 stude nt, average student. PHYSICAL EXAMINATION: GENERAL SURVEY: awake, not in cardio respiratory distress VITAL SIGNS: BP= 100/80 HR =120 bpm RR= 22 cpm Temp= 37.2 °C SKIN: erythematous, well delineated, warm, tender area on left anterior leg, scab in Left knee, wound on anterior left leg, go od skin turgor, mucosa and lips are not dry. HEENT: anicteric sclera, pink palpebral conjunctiva, no naso aural discharge, no tonsilopharyngeal congestion, no cervicolymphadenopathy CHEST: symmetrical chest expansion, no retractions, clear breath sounds HEART; Adynamic precordium, normal rate regular rhythm, no murmur ABDOMEN: flat, Normoactive bowel sounds, soft, non tender EXTREMITIES: grossly normal extremities, full and equal pulses, no inguinal lymphadenopathy, no cyanosis, no edema ASSESMENT: Cellulitis Left Leg PLAN: For admission Patient was admitted to Pedia Ward at Rm 423 under the services of Dr.Nunez/Arollado/Reyes. Vital signs monitoring was done q4. Patient was placed on diet for age. Patient was maintained on heplock. Laboratories requested are: CBC with PC, X-Ray – left leg. Medications are: Oxacillin 750 mg TIV q6 (122.4 mkd) and Paracetamol 250 mg/5 ml, 5 ml every 4 hours PRN for fever.I and O monitoring q shift .