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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila

Patient’s Name: Gonzales, Cristel Address: 657 Intramuros Manila Age/Sex: 1/Female Date Admitted: May 27, 2008 Admitting Diagnosis: Acute gastroenteritis with moderate signs of dehydration Intestinal parasitism Severe protein energy malnutrition Physician–in-charge: Dr. Troncales/Salloman/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez

Hospital No.1841056

CLINICAL ABSTRACT This is a case of a 1 year old female who was brought in due to loose watery stools. HISTORY OF PRESENT ILLNESS 7 days prior to admission, the patient had passage of loose watery stool, mucoid, foul smelling, about 5 to 6 bouts. There was no fever but there was associated anorexia and increased thirstiness. No medications were given, no consult was done. Patient was given Gatorade. 1 day prior to admission, patient had 5 episodes of passing loose watery stools. She was given Hydrite 250 mL with 3 bottles of Gatorade. A few hours prior to admission, patient was noticed to be weak. There still was passage of loose stools, about 5 bouts, hence patient was brought to OMMC and was subsequently admitted. . PAST MEDICAL HISTORY Patient was born to a 30-year old G2P2 (2002) mother via normal spontaneous vaginal delivery at home with the help of a midwife. Birth did not have any complications. No previous hospitalizations. IMMUNIZATION HISTORY No immunizations FAMILY HISTORY The patient’s mother denies any family history of asthma, diabetes mellitus, cardiac disease or respiratory diseases. PERSONAL AND SOCIAL HISTORY: Patient lives in a shack with parents and a sibling. She was breastfed for 2 months. Drinking water comes from NAWASA, not boiled. PHYSICAL EXAMINATION: General: awake, irritable Vital Signs: HR = 110 RR = 34 Wt: 5.8 kg

Temp = 36.50C

SHEENT: dry mucosa, sunken eyeball, (+) flag sign, (+) CLAD Chest/Lungs: Symmetrical chest expansion, (-) retractions, (-) adventitious sounds, clear breath sounds Cardiac: adynamic precordium, NRRR, no murmur Abdomen: distended abdomen, (+) skin tenting, (+) visible intestinal loops, hypoactive bowel sounds, nonpalpable mass, liver edge 2-3 cm below the subcostal margin Extremities:(-) cyanosis, full pulses, no cyanosis, capillary refill > 2 sec. ASSESSMENT: Acute gastroenteritis with moderate signs of dehydration

Intestinal parasitism Severe protein energy malnutrition PLAN: For admission

Patient was admitted at the Pediatric Ward Rm. 421 under the service of Drs. Troncales/Salloman/Manalo. Laboratories requested were CBC PC, Plain film abdomen, serum Na+ and K+, blood typing, urinalysis and fecalysis. Input and output were monitored. Vital signs were monitored every 2 hours. Patient was given soft diet as tolerated. IVF: D5 IMB 500 cc at a rate of 29 ųgtts/min. Ampicillin 150 mg IV ANST q 6 hours (100 mkday) and metronidazole 200 mg IV ANST q 8 hours (103 mkday) were started.

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila

Patient’s Name: Gonzales, Cristel Address: 657 Intramuros Manila Age/Sex: 1/Female Date Admitted: May 27, 2008 Admitting Diagnosis: Acute gastroenteritis with moderate signs of dehydration Intestinal parasitism Severe protein energy malnutrition Physician–in-charge: Dr. Troncales/Salloman/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez

Hospital No.1841056

24 hour history This is a case of a 1 year old female who was brought in due to loose watery stools. HISTORY OF PRESENT ILLNESS 7 days prior to admission, the patient had passage of loose watery stool, mucoid, foul smelling, about 5 to 6 bouts. There was no fever but there was associated anorexia and increased thirstiness. No medications were given, no consult was done. Patient was given Gatorade. 1 day prior to admission, patient had 5 episodes of passing loose watery stools. She was given Hydrite 250 mL with 3 bottles of Gatorade. A few hours prior to admission, patient was noticed to be weak. There still was passage of loose stools, about 5 bouts, hence patient was brought to OMMC and was subsequently admitted. . PAST MEDICAL HISTORY Patient was born to a 30-year old G2P2 (2002) mother via normal spontaneous vaginal delivery at home with the help of a midwife. Birth did not have any complications. No previous hospitalizations. IMMUNIZATION HISTORY No immunizations FAMILY HISTORY The patient’s mother denies any family history of asthma, diabetes mellitus, cardiac disease or respiratory diseases. PERSONAL AND SOCIAL HISTORY: Patient lives in a shack with parents and a sibling. She was breastfed for 2 months. Drinking water comes from NAWASA, not boiled. PHYSICAL EXAMINATION: General: awake, irritable Vital Signs: HR = 110 RR = 34 Wt: 5.8 kg

Temp = 36.50C

SHEENT: dry mucosa, sunken eyeball, (+) flag sign, (+) CLAD Chest/Lungs: Symmetrical chest expansion, (-) retractions, (-) adventitious sounds, clear breath sounds Cardiac: adynamic precordium, NRRR, no murmur Abdomen: distended abdomen, (+) skin tenting, (+) visible intestinal loops, hypoactive bowel sounds, nonpalpable mass, liver edge 2-3 cm below the subcostal margin Extremities:(-) cyanosis, full pulses, no cyanosis, capillary refill > 2 sec. ASSESSMENT: Acute gastroenteritis with moderate signs of dehydration

Intestinal parasitism Severe protein energy malnutrition PLAN: For admission

Patient was admitted at the Pediatric Ward Rm. 421 under the service of Drs. Troncales/Salloman/Manalo. Laboratories requested were CBC PC, Plain film abdomen, serum Na+ and K+, blood typing, urinalysis and fecalysis. Input and output were monitored. Vital signs were monitored every 2 hours. Patient was given soft diet as tolerated. IVF: D5 IMB 500 cc at a rate of 29 ųgtts/min. Ampicillin 150 mg IV ANST q 6 hours (100 mkday) and metronidazole 200 mg IV ANST q 8 hours (103 mkday) were started. COURSE IN THE WARDS: On the 1st hospital day, patient was weak, with pasty stool, no vomiting, eyeballs not sunken, moist lips. Patient was maintained on DAT with SAP. IVF was maintained on D5 IMB 500 cc + 20 meqs KCl x 24 hours at 33-34 cc/hr. patient was requested for serum Na and K, and for CXR. Patient was given Vitamin A 200,000 IU and vitamin K 30 mg IU. Patient was started on Prozinc syrup 1 ml OD. Patient was monitored for frequency and consistency of stool. Vital signs were monitored q2.

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila

Patient’s Name: Gonzales, Cristel Address: 657 Intramuros Manila Age/Sex: 1/Female Date Admitted: May 27, 2008 Admitting Diagnosis: Acute gastroenteritis with moderate signs of dehydration Intestinal parasitism Severe protein energy malnutrition Physician–in-charge: Dr. Troncales/Salloman/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez

Hospital No.1841056

48 hour history This is a case of a 1 year old female who was brought in due to loose watery stools. HISTORY OF PRESENT ILLNESS 7 days prior to admission, the patient had passage of loose watery stool, mucoid, foul smelling, about 5 to 6 bouts. There was no fever but there was associated anorexia and increased thirstiness. No medications were given, no consult was done. Patient was given Gatorade. 1 day prior to admission, patient had 5 episodes of passing loose watery stools. She was given Hydrite 250 mL with 3 bottles of Gatorade. A few hours prior to admission, patient was noticed to be weak. There still was passage of loose stools, about 5 bouts, hence patient was brought to OMMC and was subsequently admitted. . PAST MEDICAL HISTORY Patient was born to a 30-year old G2P2 (2002) mother via normal spontaneous vaginal delivery at home with the help of a midwife. Birth did not have any complications. No previous hospitalizations. IMMUNIZATION HISTORY No immunizations FAMILY HISTORY The patient’s mother denies any family history of asthma, diabetes mellitus, cardiac disease or respiratory diseases. PERSONAL AND SOCIAL HISTORY: Patient lives in a shack with parents and a sibling. She was breastfed for 2 months. Drinking water comes from NAWASA, not boiled. PHYSICAL EXAMINATION: General: awake, irritable Vital Signs: HR = 110 RR = 34 Wt: 5.8 kg

Temp = 36.50C

SHEENT: dry mucosa, sunken eyeball, (+) flag sign, (+) CLAD Chest/Lungs: Symmetrical chest expansion, (-) retractions, (-) adventitious sounds, clear breath sounds Cardiac: adynamic precordium, NRRR, no murmur Abdomen: distended abdomen, (+) skin tenting, (+) visible intestinal loops, hypoactive bowel sounds, nonpalpable mass, liver edge 2-3 cm below the subcostal margin Extremities:(-) cyanosis, full pulses, no cyanosis, capillary refill > 2 sec. ASSESSMENT: Acute gastroenteritis with moderate signs of dehydration

Intestinal parasitism Severe protein energy malnutrition PLAN: For admission

Patient was admitted at the Pediatric Ward Rm. 421 under the service of Drs. Troncales/Salloman/Manalo. Laboratories requested were CBC PC, Plain film abdomen, serum Na+ and K+, blood typing, urinalysis and fecalysis. Input and output were monitored. Vital signs were monitored every 2 hours. Patient was given soft diet as tolerated. IVF: D5 IMB 500 cc at a rate of 29 ųgtts/min. Ampicillin 150 mg IV ANST q 6 hours (100 mkday) and metronidazole 200 mg IV ANST q 8 hours (103 mkday) were started. COURSE IN THE WARDS: On the 1st hospital day, patient was weak, with pasty stool, no vomiting, eyeballs not sunken, moist lips. Patient was maintained on DAT with SAP. IVF was maintained on D5 IMB 500 cc + 20 meqs KCl x 24 hours at 33-34 cc/hr. patient was requested for serum Na and K, and for CXR. Patient was given Vitamin A 200,000 IU and vitamin K 30 mg IU. Patient was started on Prozinc syrup 1 ml OD. Patient was monitored for frequency and consistency of stool. Vital signs were monitored q2. On the 2nd hospital day,

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila

Patient’s Name: Gonzales, Cristel Address: 657 Intramuros Manila Age/Sex: 1/Female Date Admitted: May 27, 2008 Admitting Diagnosis: Acute gastroenteritis with moderate signs of dehydration Intestinal parasitism Severe protein energy malnutrition Final Diagnosis: AGE with moderate signs of dehydration Physician–in-charge: Dr. Troncales/Salloman/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez

Hospital No.1841056

Patient Discharge Summary This is a case of a 1 year old female who was brought in due to loose watery stools. HISTORY OF PRESENT ILLNESS 7 days prior to admission, the patient had passage of loose watery stool, mucoid, foul smelling, about 5 to 6 bouts. There was no fever but there was associated anorexia and increased thirstiness. No medications were given, no consult was done. Patient was given Gatorade. 1 day prior to admission, patient had 5 episodes of passing loose watery stools. She was given Hydrite 250 mL with 3 bottles of Gatorade. A few hours prior to admission, patient was noticed to be weak. There still was passage of loose stools, about 5 bouts, hence patient was brought to OMMC and was subsequently admitted. . PAST MEDICAL HISTORY Patient was born to a 30-year old G2P2 (2002) mother via normal spontaneous vaginal delivery at home with the help of a midwife. Birth did not have any complications. No previous hospitalizations. IMMUNIZATION HISTORY No immunizations FAMILY HISTORY The patient’s mother denies any family history of asthma, diabetes mellitus, cardiac disease or respiratory diseases. PERSONAL AND SOCIAL HISTORY: Patient lives in a shack with parents and a sibling. She was breastfed for 2 months. Drinking water comes from NAWASA, not boiled. PHYSICAL EXAMINATION: General: awake, irritable Vital Signs: HR = 110 RR = 34 Wt: 5.8 kg

Temp = 36.50C

SHEENT: dry mucosa, sunken eyeball, (+) flag sign, (+) CLAD Chest/Lungs: Symmetrical chest expansion, (-) retractions, (-) adventitious sounds, clear breath sounds Cardiac: adynamic precordium, NRRR, no murmur Abdomen: distended abdomen, (+) skin tenting, (+) visible intestinal loops, hypoactive bowel sounds, nonpalpable mass, liver edge 2-3 cm below the subcostal margin Extremities:(-) cyanosis, full pulses, no cyanosis, capillary refill > 2 sec.

ASSESSMENT: Acute gastroenteritis with moderate signs of dehydration Intestinal parasitism Severe protein energy malnutrition PLAN: For admission

Patient was admitted at the Pediatric Ward Rm. 421 under the service of Drs. Troncales/Salloman/Manalo. Laboratories requested were CBC PC, Plain film abdomen, serum Na+ and K+, blood typing, urinalysis and fecalysis. Input and output were monitored. Vital signs were monitored every 2 hours. Patient was given soft diet as tolerated. IVF: D5 IMB 500 cc at a rate of 29 ųgtts/min. Ampicillin 150 mg IV ANST q 6 hours (100 mkday) and metronidazole 200 mg IV ANST q 8 hours (103 mkday) were started. COURSE IN THE WARDS: On the 1st hospital day, patient was weak, with pasty stool, no vomiting, eyeballs not sunken, moist lips. Patient was maintained on DAT with SAP. IVF was maintained on D5 IMB 500 cc + 20 meqs KCl x 24 hours at 33-34 cc/hr. patient was requested for serum Na and K, and for CXR. Patient was given Vitamin A 200,000 IU and vitamin K 30 mg IU. Patient was started on Prozinc syrup 1 ml OD. Patient was monitored for frequency and consistency of stool. Vital signs were monitored q2. On the 2nd hospital day, patient was advised to go home with the following medications: Cotrimoxazole 200mg/40mg/5ml 2.5ml BID for 7 days, Prozic syrup 2.5ml OD for 2 weeks. Patient was advised to increase oral fluid intake at home. Patient was advised to follow-up after 3 days. LABORATORY SUMMARY: COMPLETE BLOOD CELL COUNT WITH PLATELET COUNT Normal Values 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 May 27 14.4 3.81 10.7 521 54.6 34.7 10.3 0.4

WBC RBC HGB PLATELET NEUTROP LYMPHO MONO EOSINO

Fecalysis: 05/27/08 Color: brown Consistency: Semiformed Pus: 0-1 RBC: 0-1 Ova: no ova or parasite seen Fat globules occasional


				
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