obena-24 by dredwardmark


									OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics NAME: Obena, Nico M. Hospital Number: 1831995 AGE/SEX: 7 year old/M Room No. Room Gastro ward ADDRESS: 2230 Int., 14 Leveriza, Malate, Manila DATEOF ADMISSION: May 5, 2008 ADMITTING DIAGNOSIS: AGE with moderate signs of dehydration t/c Amoebiasis Severe Protein Energy Malnutrition PHYSICIANS-IN-CHARGE: Dr. Troncales/Dr. Salloman/Dr. Manalo CLERKS-IN-CHARGE: Morilla/Naungayan/Ocampo/Orbeta/Gloria 24-HOUR HISTORY Informant: mother % Reliability: 90% Chief Complaint: weakness This is a case of a live baby boy born full term to a 28 year old G5P4 (4-0-1-4) via NSD at this institution. HISTORY OF PRESENT ILLNESS: 2 days prior to admission, the patient had non-productive cough and undocumented fever. Paracfetamol (89 mkd) was given and was relieved. He had loose watery stools, mucoid-straked, nonbloody, about 20-30 ml, 3x. No medication was given for the diarrhea. 1 day prior to admission, he had fever and non-productive cough. Paracetamol, with the same mkd, was given. Diarrhea was persistent and was not treated. There was also loss of appetite and vomiting. The vomitus immediately followed meal intake. Few hours prior to admission, he had persistence of symptoms. Diarrhea was still persistent, 2x. The rewa sno fever. He also had generalized weakness manifested by decreased activity such as playing, hence consult.

PAST MEDICAL HISTORY: Pre-natal: The patient’s mother had 3 prenatal check-ups. No multivitamins and ferrous sulphate was taken. No maternal illnesses. Birth: born full term to a 28 year old, G5P4 (4-0-1-4) mother via NSD at this institution. Post-natal: No cardiorespiratory distress. No jaundice. No previous illnesses. Feeding: He was breast fed from birth up to present. Solid foods was given at 9 months. No other artificial milk was given. Growth and Development: Patient is at par with age Immunization: (+) BCG, 1 dose. (+) DPT, 3 doses. (+) OPV, 3 doses. (-) Hepa B.

FAMILY HISTORY: (+) cardiovascular disease – maternal side (+) asthma – paternal side (-) DM (-) renal disease (-) cancer PERSONAL AND SOCIAL HISTORY: The patient lives with other 6 members of the family in a congested ommunity. They occupy one room in an apartment which is well ventilated. They have one common bathroom with toilet bowl, pour-flush type. The patient has no exposure to PPTB patients. He had exposure to cigarette smokes inside the room. The patient’s source of drinking water is from MWSS, not boiled. They have one domesticated bird. Garbage is collected once a day to every other day. PHYSICAL EXAMINATION:

General: irritable Vital Signs:
HR = 103 bpm RR = 56 cpm Temp = 36.90 C BP: 90/40 mmHg Weight = 6.7 kg Skin: no jaundice, (+) skin tenting HEENT: Head: no scars, no tenderness Eyes: Anicteric sclera, pink palpebral conjunctiva Ears: no discharge Nose: no alar flaring and no nasal discharge Mouth/Throat: no tonsillopharyngeal congestion, dry lips and mucus membrane, no ulcerations Neck: (-) CLAD Chest/Lungs: Symmetric chest expansion, no intercostals & subcostal retraction, clear breath sounds Heart: adynamic precordium, normal rate and regular rhythm, no murmurs Abdomen: flat, hyperactive bowel sounds, soft, nontender Extremities: grossly normal, no edema, no cyanosis, weak pulses ASSESSMENT: AGE with moderate signs of dehydration t/c Amoebiasis Severe Protein Energy Malnutrition

PLAN: for admission

COURSE IN THE WARDS: The patient was admitted at the Pediatrics – Ward under the care of Dr. Troncales, Dr. Salloman and Dr. Manalo. He was monitored every hours. Input and output of fluids were recorded accurately. Milk feeding with SAP was advised. CBC with PC, BT, Blood C/S, N+K+, urinalysis, CXRAP/L were requested and facilitated. IVF D5IMB 500 cc at a rate of 34 – 35 ugtts/min (125%) was

started. Metronidazole 120 mg IV ANST (-) every 8 hours (53 mkday) was started. Glucolyte was prescribed.

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