Вы находитесь на странице: 1из 8

DEPARTMENT OF PEDIATRICS

September 4, 2015
Vasay/Castaeda/Carrillo
Admissions: 3
Referral: 0
Mortality:0
In Patients:31
Discharges:5
Absconded:0
HAMA:0
THOC: 0
th
rd
JC OPD 472/475 | 4 396/397 | 3 381/382 |KTU/EXT 383/384 | DW 386/387 | JC 478/479 | HW 469/589 | ICU 393/394/395| CVU 388/389 | CVU/EXT 486/487 | ER 166/163 | LAB 151/152/153 | XRAY 159/160 | NICU 213/214 | Pedia
313/314/428 | Dr. Abrigo 8713091/8927874 | Dr. Anchores 8713722 | Dr. Balasbas 9748775 | Dr. Cabrera 3431586 | Dr. Codeniera 8265317 | Dr. Colasito 9093120 | Dr. Crisostomo 8436395/8193863/2119142 | Dr. Dideles 8461327 | Dr. Dino
8752276/8720349 | Dr. Gatmaitan 8057585 | Dr. Llamas 4786211/8077991 | Dr. Malate 8713080 | Dr. Manalad 8360797/8753571/8748087 | Dr. Principe 3306090 |Dr. T. Miranda 874928 | Dr. T. Reyes 8727532/8711521 | Dr. A. Salonga 8713130/8788278 |
Dr. Teves 8427650/8711523 | Dr. Valdez 8421031 | Dr. Villanueva 9232581 | POISON CONTROL- 524/1078/1075/55218430 loc 231
Jonelta (3)
6C
9/3/15
2:47 PM
597853
Referral for
Pedia
Clerance and
Comanagement
6A
9/3/2015
1:50 PM
610371

MORALES,
Chelsie Ong
4M 10D/F/6.8kg
4/23/15
Pamplona 3,
LPC / Cavite

CAJURAO,
Henry Baltazar
10M 2D/M/8.6kg

Abscess Medial
Aspect of left arm

JC

YasayRonquillo

S/P I&D, L arm


(9/04)

D5 0.3 NaCl x 27-28 ugtts/mins

AGE with
Moderate signs of
dehydration

JC

Edornie
Garcia

11/01/2014
Gandara, Samar
/ Ermita, Manila

MAPUTOL,
Rosemarie
14/F/46kg
9/27/2000
Molino, Bacoor

Zinc drops 1ml OD


Racecadotril in 2-3 oz milk 10 mg sachet
TID
Paracetamol drops 0.9 ml q4 T> 37.8
Paracetamol IV 90 mg q4 T >39 C
PLR 500 x 53 cc/hr D5 0.3 NaCl 500cc x
43 cc/hr

Cabrera

6G
9/3/2015
4:03 PM
577056

Ampicillin + Sulbactam 250 mg q6 d2 6pm


Paracetamol drops 100 mg/mo; .7 ml q4 for
T> 37.8
Paracetamol 70 mg TID q4 for T > 38.5

T/C Periodic
Flaccid Paralysis

JC

Abrigo/
Salonga

Spinal Cord
Syndrome VS
Myopathy

Ibuprofen 200mg/soft gel cap q8 PRN

D5 NM 1L X 12 hrs

Binos

CBC 9/2: 4.08/0.35/117/15.6/.0.71/0.00/0.25/0.04/748


CC: abscess
3 weeks PTA, patient had fever and warmth on the
medial aspect of left arm. Consult at AP and was
given Dalacin C q6 for 1 week and Paracetamol 0.7
ml drops q4. Fever lysed and abscess was noted to
be firm. 4-5 days after, noticed enlargement of
abscess. consult and was subsequently admitted.
CBC 9/3 4.61/0.37/124/14.6/0.17/0.01/0.68/0.14/274

CC: diarrhea
4 days PTA, patient had 4 episodes of yellow watery
stools with particles non bloody, mucoid, NFS. Patient
had undocumented fever. Given Paracetamol. Fever
lysed. No consult was done.
3 days PTA, had another 4 episodes of LBM. 2 days
PTA, 4x LBM. 1 day PTA, 4x LBM.
Persistence of symptom prompted ER consult and
was subsequently admitted.
CBC: 5.20/0.43/142/8.7.0.75/0.01/0.20/0.04/318
CC: inability to walk
1 month and 7 days PTA, after an earthquake drill
done at school, patient suddenly developed chest
pain, shortness of breath and extremities weakness.
Pts extremities were soaked in herbal medication
which provided relief so that the patient was able to
move her extremities again.
1 month and 2 days PTA, patient had stiff extremities
and pt was not able to walk.
28 days PTA, pt was able to move upper extremities
again.
10 days PTA, pt was not able to move her lower
extremities by moving her buttocks.
1 day PTA, a midwife relative saw the pts condition
and she advised to have the patient seen at the
hospital, hence this admission.

UA 9/2: str/c/8.0/neg/neg/1.000/0-2/0-2/few/rare
CXR APL 9/2: NCATS
Wound discharge gs: pus cells: +3; g+cocci in
singles, in pairs and in chains: +2

UA: ly/h/6.0/-/-/1.010/2-4/0-2/e-occ/b-rare/mt-rare
SE:y/s/-gb/-m/-op/ fat globules seen
Cl: 108 (98-107)
K: 4.0
Na: 135 (137-145)

UA ty/h/6.5/-/-/1.025/0-2/1-3/few/mod
Na 139
K 4.4
Ca 1.07
CPK Total: 69.1
X-ray Thoracic and Lumbar: No demonstrable
evidence of fracture; Mild dextroscoliosis of
thoracic spine; Lumabar curvature is straightened
likely sec to muscle spasm; Posterior disc space
bet L5-S1 is narrowed; The rest of intervertebral
disc spaces, vertebral body heights and post
elements are intact.; The included sacroiliac joint
spaces are unremarkable; Incidental note of
generalized ileus.
EMG/CMV_______________________________

th

4 MAIN (8)
402
9/2/2015
2:57 pm
413152
Bonzo

SANTOS, Adriela
Ysabel F.
4/F/17kg
11/16/2010
Bacoor, Cavite

Interstitial
Pneumonia,
BAIAE
Pneumonia mod
risk

PP

Barza

Salbutamol+ipratropiumbr neb q6 (6-12-612)


Salbutamol neb q6 (9-3-9-3)
Cefuroxime 500mg IV q8 D3 9/5 8am
Hydrocortisone 70mgIV q6
Paracetamol 250mg/5ml 4ml q4 for
T>=37.8
D5 IMB 500cc x 79-80cc/hr heplock

405-A
9/1/15
2:15 am
276775
Cabrera

PITAO, Jervis
Angelo
12/M/54 kg
02/19/2003
LPC

AGE with some


dehydration

PPI

Fuentes

Zinc sulfate syrup 5 ml OD


Erceflora vial,1 vial BID
D5 0.9 NaCL 1L x 68 gtts/miin

CBC 9/2 4.35/.38/128/13.2/.72/.01/.20/.07/311

CXR AP/L (o): Interstitial Pneumonia

CC: fever
3 wks PTA, (+) cough nonproductive, (+)
undocumented fever. No consult done, noe meds
2 wks PTA, (+) persistent cough given Clarithromycin
for 1 week, with relief
1 day PTA, cough recurrence productive, (+)
undocumented fever, given Paracetamol, noted relief
Morning PTA, (+) slight DOB, with retractions, neb
started with Budesonide and Ipratropium br, affording
slight relief. (+) 1 episode of vomiting noted after
giving cefuroxime, due to persistence of symptoms
brought to ER, subsequently admitted
CBC 9/4 4.96/.39/130/12.4/.74/.04/.15/.07/285
CC: vomiting and LBM
2 days PTA, patient had 2 episodes of vomiting of
PIF and 3-5 episodes of brownish watery stools, non
bloody non mucoid, NFS. With noted abdominal pain.
1 day PTA, persistence of vomiting of PIF (2x) and
LBM (3-5x). still with abd pain. No fever. Few hours
PTA, persistence of symptoms prompted ER consult
was subsequently admitted.

UA dy/st/6.0/tr/-/1.030/6-8/0-2/rare/few/mod
Fecalysis: yb/w/-gb/-m/none seen ova

406-A
9/3/2015
4:52 PM
466415

TRINIDAD,
Hoaquin
8/M/21kg

URTI

HCI

Barza

5/22/2007
LPC

Clarithromycin 250/5 3.5 ml BID D2 9/5


6pm
Paracetamol 250/5 5ml Q4 PRN for T>37.8
C
Salbutamol nebulization 1 nebule Q6
Nasatapp syrup 5ml TID
Dulcolax syrup 1x given

Binos
D50.9 NaCl 500 cc x 79 cc/hr D5 NM
52-53 cc/hr

406-B
9/2/2015
8:04 pm
427190
Bonzo

MUDANZA,
DjhalzDazner L.
14/F/34kg

DFS DHF I

PPI

Principe

08/12/2001
LPC

Paracetamol IV 350mg q4 for T >39 C


Paracetamol 250/5 7ml q4 for T>37.8 C
Cetirizine syrup 9ml BID po

AFABLE, Maurize
Carlino Guamos
1/M/12kg

HFMD

PPI

MendozaMedrano

Kamillosan spray TID


Isoprinosine 250/5 2.5ml TID
Paracetamol 250/5 2.5ml Q4
Paracetamol 120mg IV Q4
Cetirizine 2.5mg/5ml 2.5ml single dose
D5 0.3 NaCl x 75cc/hr

Carrillo

Cabrera

TATLONGHARI,
Chloe Isabelle L,
1/F/12 kg

CFC T/C UTI


measles

PPI

Viola/
Salazar

10/11/2013
LPC

Cefuroxime 375mg IV q8 D3 9/5 12nn


Paracetamol 250/5 2.5ml q4 T>37.8
Paracetamol 120mg TIV q4 T>38.5
Diazepam 2.5mg IV for frank seizure PRN
Combvent 1 neb q 12
Diphenhydramine 12 mg IV q 12
Vitamin A 1000 IU SL (single dose)
O2 2-4 lpm via FM prn for active seizure
D5 0.3 NaCl 500cc x 55cc/hr (FM+20)
D5 IMB 500cc x 45 cc/hr (FM+20%) D5
IMB 500cc x 45 cc/hr (FM)

430
8/31//2015
9:27 am
610082

ROQUE, Venice
Margaux
6m27d/F/8kg
2/4/2015
Pasay City/LPC

Binos

UA: ly/h/6.5/neg/neg/1.010/0-3/2-4/rare/few
UA: s/h/7.0/-/-/1.015/3-5/0-2/rare

DVT IgM positive, IgG negative


UA 9/3: y/st/7.0/trace/-/1.010/15-20/1-3/few/rare
Rpt UA: s/h/7.5/-/-/1.015/1-3/3-5/many

CC: rashes

10/22/2013
LPC

360 417
9/2/2015
7:42 am
606497

CC: fever and worsening cough


10 days PTA, patient had colds with greenish to light
yellow secretions and phlegm with the same color. (-)
fever. No meds taken.
5 days PTA, pt developed fever (Tmax 38.6).
Paracetamol was given RTC.
4 days PTA, pt had 1x post-tussive vomiting of small
amount. Pt also had decreased appetite.
3 days PTA, still with fever, (+) 1x post-tussive
vomiting
2 days PTA, (+) post-tussive vomiting noted. Still with
fever. Paracetamol given RTC
1 days PTA still with fever. Now, phlegm is difficult to
expectorate and coughing is has became difficult.
Few hours PTA, persistence of fever prompted Er
consult, hence admission,
CBC 9/2 4.67/.39/127/3.6/.28/.04/.58/.10/192
CBC 9/3 4.63/.39/127/3.8/.28/.02/.58/.12/188
CBC 9/4: 4.32/0.36/125/3.6/.33/.03/.52/.12/182

D5 LR 1L x 7H

DTR

409
9/4/15
2:37pm
577243

CBC: 3.99/0.35.115.8.6/0.63/0.02/0.23/0.12/290

Pneumonia, Mod.
Risk
Measles

PPI

Viola/
Salazar

Cefuroxime (Zegen) 250 mg IV Q8 D5 9/5


4am
Paracetamol drops 0.8 ml q4 PRN for
T>37.8 C
Paracetamol 80 mg IV q4 PRN for T> 39 C
Vit A 50,000 u 2 gel capsules DC
Cetirizine drops 1 ml ODHS_-DC
E-zinc drops o.5 ml OD
Duavent 1 nebuleQ8q12

4 days PTA, noted intermittent fever Tmax 38 C,


given 500mg tab, also note of (+)headache, muscle
pain, vomiting PIF, and dec in appetite. Sought
consult and was diagnosed as flu, and prescribed
paracetamol 500mg tab. (-) no note of bleeding.
1 day PTA, noted no fever episode anymore.
9 hours prior to admission, persistence of the
previous symptoms other than fever, now with
appearance of diffuse slightly pruritic maculopapular
rashes.
Few hours PTA, patient brought to ER, and
subsequently admitted
CBC 9/4: 3.96/.34/113/12.8/.74/.01/.20/.05/257
CC: Fever
2 days PTA, patient had an undocumented fever.
Paracetamol half tsp was given which afforded
temporary relief.
1 day PTA, patient had 1 episode of vomiting, noted
to have decrease in appetite, and throat pain due to
mouth sores. Patient still with fever. Paracetamo was
taken and an ointment was used for mouth sores.
Few hours PTA, pesisitence of sympoms prompted
ER consult and was subsequently admitted,.
CBC 9/2 4.09/.34/119/15.2/.82/.01/.12/.05/243
CC: seizure
1 day PTA, (+) fever Tmax 38 C. No noted vomiting,
cough, colds, LBM, or seizure. Paracetamol drops
1ml q4 given, afforded temporary relief. No consult
done.
5 hrs PTA, still with fever (undocumented) assoc with
1x vomiting PIF/milk, 4 oz, nonprojectile. Paracetamol
continued.
3 hrs PTA, still with fever and 1x vomiting PIF/milk .
Patient given Paracetamol. No other symptoms
noted. Then patient had 1 episode of convulsion
characterized as upward rolling of eyeballs and
stiffening of upper and lower extremities which lasted
for 2-3 mins assoc. with LOC lasting for less than a
minute.Patient rushed to a nearby hospital, where she
was given paracetamol, O2 inhalation, nebulization
and IVF. Patient noted to be weak and deep
breathing after the seizure. Patient transferred to our
institution for evaluation and further management.
CBC: 4.87/.40/134/8.9/0.30/0.01/0.60/0.09/262
CC: rashes
4 days PTA, (+) nonproductive cough, (+) colds with
watery secretions noted. With associated fever (Tmax
39.3C) and LBM 3-4x. No vomiting. With good
appetite. Given Paracetamol 1 ml which provided
temporary relief.
3 days PTA, symptoms persisted. No consult done.
2 days PTA, consult done at ihealth. Given meds:

UA : ly/c/6.5/1.010/-/-/0-1/0-2/ec-rare
CXR (o): Interstitial Pneumonia
CBG 153 mg/dl
Na 136 N
K 5.0 N
Cl 101 N
Mg 0.98 N

UA: ly/h/6.5/-/-/1.015/0-2/1-3/rare/rare
CXR APL(o): NCATS

D5 IMB 500cc x 33 ugtts/min (FM)

442
9/2/2015
2:35 pm
417360
Binos

MEJALA, Prince
Joshua P.
4/M/15kg

BAIAE, PCAP C

PPI

Viola/
Salazar

01/22/2011
LPC

Salbutamol+Ipratropiumbr (Duavent)1 neb


q8 (9am-9pm)q12 Q6
Salbutamol neb q6 (7-3-10)q8- DC
Hydrocortisone (Solucortef) 60mg IV
q6q8-> Q6
Cefuroxime 500mg IV q8 d2+1
Clarithromycin (Klaricid) 250/5 2.5ml Q12
D1 9/5 8am
Diphenhydramine 15mg IV BID (1mkdose)DC
O2 via NC at 2-4 lpm Discontinued
D5 0.3 NaCl 500cc x 52cc/hr 39cc/hr

ambroxol, paracetamol, unrecalled meds for the gums


(pts central mandibular tooth is erupting).
1 days PTA, erythematous maculopapular rashes on
the face and neck noted. With fever, 2x vomiting, 3-4x
BM.
Morning PTA, rashes progressed including the
extremities and trunk. Pt was brought to the ER and
was subsequently admitted.
CBC 9/2 4.35/.35/117/13.2/.79/.01/.12/.08/367
CC: DOB
4 days PTA, pt developed nonproductive cough and
colds. Skin is noted to be warm to touch. No meds
given.
3 days PTA, L eye noted to be swelling, consult done,
Maxitrol prescribed. Parent did not comply because
theyre not convinced it was conjunctivitis.
2 day PTA, cough became productive. No consult
done.
1 day PTA, still with cough now with labored
breathing. Pt also complains of abdominal pain.
Nebulization done which didnt provide relief.
Few hrs PTA, symptoms persisted which prompted
consult at the ER resulting to subsequent admission.

UA dy/h/6.0/trace/neg/1.030/1-2/5-7/few/mod
CXR AP (o): NCATS
CBG 73 mg/dl
Na 140 N
K 4.3 N

rd

3 MAIN (8)
CVU13-A
302B
9/2/2015
11:44 pm
189129

AIZAWA, Megumi
P.
12/F/38kg

DFS

PP

Principe

06/15/2003
LPC

Paracetamol 250/5 8ml q4 T> 37.8


Paracetamol 1 amp T >39

CBC 9/3 4.47/.40/135/5.2/.75/-/.16/.09/169


CBC 9/4: 4.46/.41/133/4.0/.61/0/.30/.09/175

D5 LR 1L x 114cc/hr D5 LR 1L x 6
hours

CC: Fever
1 day PTA, in the afternoon, noted undocumented
slight fever. At around evening, documented temp at
38.5 C, patient given Paracetamol 500mg tab, noted
relief of fever after 30 mins. There was also note of
abdominal pain. Patient denies vomiting or bleeding.
Noted BM of watery yellow stool.
Few hours PTA, consulted with AP, and request for
NS1 given, noted positive result, and they then went
to ER, and patient subsequently admitted.
CBC 9/4 AM: 4.53/.38/126/12.0/.70/.04/.17/.09/298
CBC 9/4 PM: 4.36/.37/121/9.9/.72/--/.18/.10/324

Bonzo

302 C
9/4/15
8:52am
437269

VELARDE,
Emmanuel Louis L.
4/M/23kg

T/C
Appendicitis
Functional
Constipation

BANIAE, URTI

PPI

Principe

Fleet enema
D5 LR 78 cc/hr 65cc/hr

12/25/2010
LPC
Bonzo

312
9/2/2015
10:18 am
508509

JUNIO, Robin C.
2/M/14kg

PPI

Codeniera

05/05/2013
LPC

Binos

Cefuroxime 500 mg SIVP q8 D2 8/5 8am


Clarithromycin 125mg/5ml 4 ml q12 D2 9/5
8pm
Paracetamol 200mg IV q4 T>=37.8C
Paracetamol 250/5 3ml q4 T>=37.8C
Salbutamol neb q6
D5 0.3 NaCl 500cc x 50cc/hr
D5 NaCl 500cc x 60cc/hr (FM+20%)

303
9/1/15
8:47PM
605202

MALIMUTIN, Brielle
Nicole
2/F/11kg
2/14/2013

Acute
Bronchitis;
Acute
Conjunctivitis

PP

Custodio

Cefuroxime 275mg IV q6 shift to


Co Amoxiclav 228.5/5 5ml BID PO D3 9/5
8am
Maxitrol Eye Ointment TID
Paracetamol 120mg/5ml (5ml) Q4 =/>37.8

CC: Abdominal Pain


2 days PTA, patient started to have intermittent fever
with Tmax 38.8 and throat pain, they sought consult
with AP and was assessed as acute
Tonsillopharyngitis. Patient prescribed with Dolan and
Co Amoxiclav. There was also noted od decrease in
appetite.
1 day PTA, around 2am, patient had 1 episode of
vomiting. There was persistence of int. fever. Patient
also started to experience abdominal pain, more
specifically in the epigastric pain. Medications
continued.
5 hours PTA, symptoms persisted and abdominal
pain became very severe and the patient was then
brought to ER. Hence this admission
CBC 9/2 5.21/.42/139/14.1/.68/-/.29/.03/244
CC: fever
2 weeks PTA, (+) on and off fever nonproductive
cough and colds noted skin warm to touch esp. at
night or dawn. Warmth noted to resolve the next day
following the symptoms, no consult done.
3 days PTA, persistence of above symptoms, now
with documented fever Tmax 39. Tempra and
Asmalin given with provided temporary relief.
2 days PTA, symptoms persisted.
1 day PTA, consult was done at ER, but was not able
to come back for the results. Now, with loss of
appetite. Morning PTA, fever persisted. Patient
subsequently admitted.
CBC: 4.02/.36/120/8.2/.36/.03/.53/.08/207
CC: sore eyes
7 days PTA, (+) colds. Paracetamol 250mg/5ml (5ml)
taken.

UAy/st/7.0/trace/neg/1.010/3-6/4-6/ec many/ bacte


mod
DNS1 Ag pos

UA: y/h/6.0/tr/-/1.025/0-2/4-6/ec-few/b-mod
Abd xray (o): mild ileus
Whole Abd UTZ: Normal L,GB,P S and K; Non
dilated ureters; Probe elicited tenderness both
lower quadrants, Neg for intraperitoneal fluid
collection

UA y/h/6.0/neg/neg/1.020/0-1/3-4/rare/occ
CXR (o): Interstitial Pneumonia
DNS1 Ag neg, IgM neg, IgG neg

UA:ly/h/6.0/-/-/1.010/0-1/0-2/ecocc/bacte rare
CXR APL (o): NCATS

LPC

Salbutamol neb q8

Carrillo
D5 0.3 NaCl x 41-42cc/hr
Still MGH

307
9/2/2015
4:09 pm
523423
Bonzo

NEPOMUCENO,
Christian Keith S.
1/M/11kg

Simple Febrile
Seizure

BFC sec to UTI

PPI

Principe

Cefuroxime (Profurex) 400mg TIV q8 D3


9/5 10am
Paracetamol 110mg IV T>38.5 prn
Paracetamol 120/5 5ml T>37.8 RTC PO

11/28/2013
LPC
Combivent 1 neb q4- DC
O2 at bedside
Diazepam 1.1mg IV for frank seizure
Cetirizine syrup 3.5ml BID
D5 IMB 500cc x 35 ugtts/min

308
9/2/2015
8:32 pm
489075
Bonzo

SAN MIGUEL,
Jayden Sayen M.
2/M/13.5kg

ATP with some


dehydration

PP

Aseron

08/16/2013
LPC

Co- Amoxiclav IV 500mg IV q12 D1


completed 228.3/5 2ml Q12 D2 9/5 8am
Paracetamol 130mg IV q4 T>37.8
D5 0.3 NaCl 500cc x 8H
D5 IMB 500cc x 47-48 cc/hr

327A
9/2/2015
7:45 pm
610306
Bonzo

327-C
9/2/2015
6:05pm
467314
Bonzo

COTEJAR,
Princess Eiram C.
5/F/17.8kg

DFS

PPI

Principe

Paracetamol 250/5 4ml q4, prn T>37.8


Paracetamol 180mg IV q4, prn T>39

6 days PTA, (+) colds


4 days PTA, (+) colds, consult ER given with
Paracetamol and Cetirizine 3ml ODHS.
3 days PTA, (+) non productive cough, colds, and
sore eyes with minimal clear discharge, and LOA.
2 days/ 1 day PTA, above mentioned symptoms.
Persistence of symptoms prompted ER consult.
Hence this admission
CBC 9/2 4.73/.37/130/8.3/.66/.03/.20/.11/200
CC: seizure
2 days PTA, patient noted to have fever of 38 C,
Paracetamol 250/5 3ml given every 5 hours, noted
fever relief. There is assoc. (+) occ nonproductive
cough, (+) occ clear nasal discharge. No consult
done. Above symptoms persisted until.
3 hours PTA, noted upward rolling of eyeballs, and
stiffening of extremities, w/c lasted for less than a
minute, and noted chills after wards. Patient was then
immediately rushed to the ER, and subsequently
admitted.
CBC 9/2 4.28/.36/123/16.0/.88/.01/.07/.04/283

Na 134 N
K 4.3 N
UA ly/h/6.0/trace/neg/1.020/1-2/8-12/ecocc/bacte
rare

UA dy/h/6.0/t/-/1.030/rbc/1-3/3-5/few/rare

CC: fever
2-3 days PTC, patient complained of occasional
throat itchiness, no consult done nor medications
given
Morning PTA, noted increase in temp, given Calpol
drops 2ml, noted temporary relief.
5 hours PTA, noted another fever episode given
Paracetamol but this time with no noted fever relief.
3 hours PTA, they sought consult to AP and was
advised admission.
CBC 9/2 5.09/.39/134/14.9/.83/-/.10/.07/423
CBC 9/3 5.2/.4/136/7.7/.52/.01/.35/.12/346
CBC 9/4: 5.15/.41/132/5.5/.53/.01/.39/.07/325

NS1 Ag pos, IgM neg, IgG neg


UA y/h/6.0/-/-/1.030/0-2/4-5/ecocc/bacte few

D5 LR 500cc x 75cc/hr
08/24/2010
LPC

YUMOL, Stephany
Benette E.
18/F/50kg

CC: fever
1 week PTA, (+) occ cough, with whitish sputum,
given tsp, of Robitussin.
1 day PTC, still with occ cough, now with assoc.
undocumented fever, given Paracetamol (Tempra)
250/5 5ml, which afforded only slight relief, and
headache.
Morning PTA, noted temperature of 39 C, patient
brought to ER and noted temp of 38.2. Patient
subsequently admitted.
DFS

HCI

Llamas

09/26/1996
Pque

Paracetamol 500mg tab PO q4 T> 37.8


Paracetamol 1 amp q4 T>39.0
Ranitidine 1 amp OD

CBC 9/2 4.54/.38/125/3.4/.56/-/.35/.09/158


CBC 9/4 4.49/.38/127/2.0/.38/.03/.44/.15/132
CBC 9/5:

D5 LR 1L 100cc/hr PNSS 1L x 12 hours

CC:fever
3 nights PTA, noted undocumented fever, no
medication was given. (+) abdominal pain, headache.
2 days PTA, documented tem at 38.4 C, patient given
Paracetamol (Biogesic) 500mg 1 tab every 4 hours,
still with note of abdominal pain specifically in the
epigastric area. No consult was done.
1 day PTA, patient still with intermittent fever,
documented at 39.2 C, there was also note of loss of
appetite, >10x episode of nonprojectile vomiting, of
clear phlegm. Patient denies presence of cough, cold,
or bleeding. Sought consult at Pal Medical at Nichols,
Pasay City, where the private practitioner considered
Dengue. CBC advised to be done.
Morning PTA, CBC done w/c reveals possible viral
etiology, patient afterwards was admitted.

UA dy/st/7.5/trace/-/1.015/many/0-2/rare/rare
DNS1 Ag IgG IgM
BT O Rh pos
PT13.2/13.6/1.04/94%
PTT 39.7/29.2

KTU (6)
333A
9/3/2015
6:36 PM
414668

ADRALES, Franz
Gabrielle
5/M/16.5kg
4/28/2010
LPC

Acute
Bronchitis

PPI

Principe

Cefuroxime 600 mg IV Q8 D2 9/5 12nn

CBC: 4.71/0.38/126/5.8/0.64/0.01/0.23/0.12/285

Paracetamol 164 mg IV Q4 PRN for T> 39 C


Paracetamol 250/5 3.5 ml q4 PRN for fever
Combivent 1 neb q2 Q3

CC:cough
6 days PTA, pt developed non-productive cough with
assoc. Fever (Tmax of 40.2). Paracetamol was given.
5 days PTA, consult was done. Dengue test done

UA: y/h/6.5/0-2/0-2/rare/rare/m. threads mod


CXR (done as OPD) (o): NCATS

Binos

333D
9/1/15
8:51AM
610134

D5 NM 1L x 55cc/hr

TURLA,
JimraldReuel
Mojica
6/M/22kg
10/20/2008
Manila / LPC

ATP Non
Exudative T/C
UTI
ATP;Systemic
Bacterial
Infection

PP

Balasbas

Carrillo

335
8/31/2015
5:14 PM
487400
Cabrera

Cefuroxime 500mg IV D3 9/4 4AM D3 9/4


4am shift to Ceftriaxone 1 gm q 12- D2 9/5
6am
Paracetamol 250mg/5ml Q4 PRN
Paracetamol 220mg IV if >/= 39 >/=
Paracetamol 220mg IV 38.5 C
D5 0.9 NaCl x 85 cc/hr D5NM 1L x
70cc/hr

ICASIANO, Nathan
2/M/11kg

Acute
Bronchitis T/C
Pneumonia

PPI

Baradi

Salbutamol 1 neb q 6
Paracetamol 250/5 2.5ml PRN
Cefuroxime 250 IV q6 D5 9/5 12NN
Ventolin expectorant 3 ml TID

7/26/2013
LPC
D5 IMB 500cc x 48-49cc/hr (FM+10) D5
IMB 500cc x 43-44c/hr (FM)

338
8/31/2015
2:00 PM
610109
Binos

339
9/3/2015
1:34 pm
604221
Carrillo

GARIN, Brayden
Marcus G.
1m5d/M/4.6kg
7/27/2015
LPC

MITTON,Patrick
Ezekiel
2 mos/M/6.2 kg

Partial Gut
Obstruction T/C
Hirschprung
Disease Vs.
Intussusception
Gut
o
Obstruction 2
to Incarcerated
Inguinal Hernia
with testicular
infarction, Right
S/P Inguinal
Exploration,
reduction of
incarcerated
small bowel,
Herniotomy,
Orchiectomy R
T/C UTI

PPI

Viola
Catangui
/Lunas

Cefuroxime 150 mg IV Q8 D4 9/4 8AM


Amikacin 70 mg IV OD D4 9/4 6PM
Paracetamol 50 mg IV q4 PRN for T>37.8
Ranitidine 5 mg IV Q12
Start MF 10cc Q3
D5 IMB 500cc x 20cc/hr15cc/hr

PP

Principe

7/02/2015
LPC

INALDO, Jaime
Inigo L.
2/M/19kg
11/01/2012

ATP NE with
mod sign of dhn

CC: Fever
2 days PTA, patient had intermittent fever TMax 39.0
accompanied with headache, body malaise. No other
associated symptoms like cough and colds.
Paracetamol was tajen 7ml Q6 which afforded
temporary relief.
1 day PTA, still with fever TMax 39.5 with above
mentioned symptoms. Patient noted vomiting PIF.
Paracetamol 7ml taken.
Persistence of above mentioned symptoms ptompted
ER consult. Hence this admission
CBC: 4.56/.36/117/8.4/.46/.04/.38/.12/547
CC: poor oral food intake, cough
6 days PTA, patient had fever (Tmax: 38 C)
associated with productive cough, 1 episode of
vomiting of previously ingested milk and decreased
appetite. No colds, DOB, LBM, rash noted. Patient
was given Paracetamol 250/5 which afforded
temporary fever relief. No consult was done.
5 days PTA, still with above symptoms.
4 days PTA, patient still with cough and decreased
appetite but no more fever. No meds given and no
consult was done.
Persistence of poor oral food intake prompted ER
consult and was subsequently admitted.
CBC: 3.5/0.34/113/9.7/0.28/0.03/0.56/0.13/495
5 days PTA, (+) vomiting nonbloody, nonbilous, (+)
phlegm, (+) colds
4 days PTA, consult done at LPMC. CXR done,
initially treated as Pneumonia. (-) BM.
3 days PTA, enlarging abdomen, (+) greenish mixed
with yellowish vomitus.
2 days PTA, abdxray and abdutz doneileus. (-) BM
1 day PTA, suppository inserted, small amount of BM
noted. OGT inserted.
Few hours PTA, due to card issues, opt to transfer
here due for pedia surgery service, hence admitted..

UA:ly/h/6.0/neg/neg/1-3/1-3/ec-few/b-few/mt-few
Typhidot IgM (-) IgG (-)
Dengue blot IgM (-) IgG (-)

CXR (o): Non specific bronchitis

Blood CS 2 sites1 site: Negative after 24 hours


of incubation; Negative after 48 hours of
incubation.
FA yb/soft/neg/0-3/neg/none seen
Occult blood positive
BT blood type B, RH+

Baseline abd girth: 42 cm37.5 cm


2

Amikacin 100mg IV OD D3 9/5 12nn


Ampicillin 320 IV Q12 D2 4am
Paracetamol 62mg IV T39
Paracetamol 100mg/ml drops .7ml Q4 T
37.8
D5 0.3 NaCl 500cc x 39 cc/hr D5 IMB
250cc x 20cc/hr

341
9/2/2015
10:29 pm
467632

negative. CXR normal. Celestamine and


Salbutamol were given.
4 days PTA, fever now low grade, still with cough.
3 days PTA, fever became persistent, still with cough.
Co-amoxiclav given as advised by a pediatrician on
his recent consult.
2 days PTA, symptoms persisted. Continued
medication
1 day PTA, still no improvement, consulted with AP
and advised admission.
CBC: 4.48/.37/124/18.6/.88/.01/.04/.07/226
CBC 9/3 4.37/0.36/116/13.4/0.72/0.01/0.19/0.08/218

HCI

Custodio

Paracetamol 190mg IV q4 T>37.8


Paracetamol 120 mg/5ml; 7.5 ml q4 T >37.8
Cetirizine syrup 2.5ml OD
Maxitrol Eye ointment BID L eye
D5 0.3 NaCl 500cc x 99cc/hr (FM+10/16)

CBC: 3.75/.31/107/6.2/.36/.01/.51/.12/280

UA: y/st/6.0/+1/neg/1.025/0-2/many/ec-rare/bmany

CC: Fever/Chills
2 days PTA, patient had intermittent undocumented
fever. No other associated symptoms like cough,
colds,d iarrhea , and vomiting noted. Patient given
with Paracetamol which afforded temporary relief.
1 day PTA, patient with intermittent fever
accompanied with colds. Paracetamol taken.
Few hours PTA, patient still with fever experienced
chills and noted to have cyanotic lips which prompted
ER consult.
At the ER, patients temperature was 39.0. No other
associated symptoms noted. Hence this admission.
CBC 9/2 5.0/.40/134/8.1/.80/.02/.07/.11/178
CC:
Morning prior to admission, patient started to
experience intermittent fever, with Tmax 38.4 C.

UA9/3: y/h/6.5/-/-/1.020/0-1/0-2/occ/few

Bonzo

LPC

DOCTORS WING (4)


351
BAJA, Raven Mae
09/01/2015
R.
10:07 PM
10/F/55kg
203931
09/14/2004
Bacoor, Cavite
Carrillo

Patient was given Paracetamol (Tempra) which


afforded partial fever relief. There was noted
occasional cough, and last bowel movement a day
before.
T/C Heart
Disease
Costochondriti
s

PPI

Principe

Combivent neb q4 and Asmavent neb q8


Salbutamol 1 neb q4
Ibuprofen 200mg/cap 1 cap (single dose)
Mefenamic acid 500 mg TID

D5 NM 1L x KVO

MGH

355
9/2/2015
11:05 pm
366024
Bonzo

ERICTA, Marietta
Eliz D.
7/F/21kg

BAIAE T/C
PCAP

PPI

Fuentes

06/28/2008
LPC

Cefuroxime 250/5 5 ml BID D3 9/5 6pm


Cetirizine syrup 5 ml ODHS
Salbutamol+Ipratropium Br 1 neb q6 Q8
Hydrocortisone 30mg q6
Prolix 10/5 5ml TID
Paracetamol 250/5 5ml q4 T>37.8
Paracetamol 210mg IV q4 T>39
Mometasone Furoate Monohydrate Aq nasal
spray 0.05% 1 spray each nostril OD

PD
356
8/29/15
1.24am
609930
Cabrera

MELGAR, Zion
Asher
8mo/M/9.7kg

Staph Scalded
Skin
Syndrome

PPI

Principe

D5 0.9 NaCl 1L x 78-79 cc/hr


Oxacillin 250mg IV q6 completed
Paracetamol 97mg IV q4 PRN T>39.0C
Paracetamol drops 1ml q4 PRN for fever
Mupirocin ointment TID to affected areas
Atopiclair 15 mins after Mupirocin TID
Atopiclair TID
Combivent neb q4

12/2/14
Muntinlupa/LPC

D5 IMB 500cc x 35cc/hr (80% FM)

MGH
357
9/4/15
8:46pm
584101
Carrillo

VIRAY, Micah
Ingrid O.
6/F/29kg

JRA; PCAP

PPI

Bueno

12/09/2008
Paranaque

Cefuroxime 750 mg IV q6 d1 6pm


Hydrocortisone 250mg IV-100mg Q6(4)Q8(3)-Q12(2)-OD(3)
Combivent + Mucosolvent Q8
D5 NM 1L x KVO

DTR

HOPE WING (2)


206
PANOPIO, James
9/3/15
William Dayrit
5:46 pm
8/M/27kg
477422
05/28/2007
Cavite / LPC
Cabrera

Acute
Bronchitis

PPI

Viola

Cefuroxime 500 mg IV 750mg IV Q8 D2


9/5 8am
Salbutamol + Ipratropium bromide (Duavent)
1 neb q8
Paracetamol 250/5 7.5 ml q4 T>/= 37.5
Paracetamol 1 amp q4 T>/= 38.5
Cherifer + Zn syrup 5ml OD
D5 0.9 NaCl 1L x 68 cc/hr

CBC 9/1: 5.37/0.44/145/12.0/.60/.01/.27/.12/294


CC: DOB/ Chest Pain
Patient recently discharge from our institution
diagnosed with AGE r/o intestinal amobebiasis t/c UTI
with some DHN.
Night PTA, patient had DOB/Chestpain. No consult
done. Patient had nebulization. Temporary relief
afforded.
14 hours PTA, patient with recurrence of DOB/Chest
pain.
9 hours PTA, patient still with above symptoms
which prompted ER consult. ECG was done which
revealed an abnormal result. Patient sought AP
consult and was advised for admission.
CBC 9/2 4.71/0.39/129/13.9/.84/.02/.06/.08/249

2D echo: good biventricular systolic function


and noral cardiac chamber sizes. No heart
dilatation. No pericardial effusion. Thinned out
portion of atrial septum with no atrial shunt
seen.
ECG: Nornal sinus rhythm, normal axis with
normal intervals, intraventricular contraction
delay in leads III, AVL non-specific ST-T wave
changes.
UA: y/h/6.5/-/-/1.025/0-3/2-4/occ
Na: 138
K: 3.8
Cl: 101
Mg: 0.8
UA y/h/6.0/neg/neg/1.010/1-3/4-6/few/few/few
CXR APL (0): NCATS

CC: vomiting
2 days PTA, patient started to have productive cough,
and colds. No fever noted. No meds given, no consult
was done.
Morning PTA, still with above symptoms noted fever
of 38.7. Patient given Calpol, and Asmalin, with noted
relief of symptoms.
Few hrs PTA, patient had 2 episodes of vomiting
watery material with phlegm, hence ER consult and
subsequent admission.
CBC: 4.61/.37/127/9.9/.52/.04/.35/.09/274

UA: dy/h/6.0/-/-/1.020/0-2/5-7/b-rare/mt-mod

CC: erythema on the face, neck, truck and


extremities; and desquamation on the left neck
2 days PTA, patient was noted to have redness o the
corner of the left eye which eventually spread around
the lip area, neck and corner of the right eye. Patient
was irritable. During the night, noted areas of
desquamation on left side of the neck. Bactroban was
applied on the affected area. No noted fever, difficulty
of breathing, vomiting. No consult was done.
1 day PTA, redness spread to the trunk and
extremities. No noted fever, DOB. Sought consult at
AP. Impression was Staph Scalded Skin Syndrome.
Hence, advised admission.
CBC 9/4: 5.07/.38/121/10/.47/.07/.40/.06/265
CC: Knee pain
2 weeks PTA, patient had cough, sought consult and
was given Klaricid 5m for 1 week.
10 days PTA, patient experienced on/off knee pain
accompanied with productive cough.
Few hours PTA, patient experienced sudden onset of
knee pain which prompted consult and was advised
for admission.

CBC 9/3 5.33/0.44/146/14.0/0.83/0.12/0.05/327


CC:
2 days PTA, patient had an onset of fever (Tmax:
38.8). He was given Paracetamol 7.5 ml every 4
hours which afforded temporary fever relief.
1 day PTA, still with fever, now with productive cough.
No colds, vomiting, DOB.
Morning PTA, persistence of on and off fever, noted
wosening of cough now with colds asscociated 1
episode of vomiting of PIF. Patient was noted to be
weak looking, with decreased appetite which
prompted consult at AP and was advised admission.

ESR: 8 (0-20)
CRP: 6mg/ml (0-10)
ASO: Negative
Creatinine: 69
BUN- 3.2
C3:
UA:
CXR (9/5):

UA ly/h/6.0/neg/neg/1.020/0-2/2-4/rare/rare
CXR APL (o): NCATS

216
9/1/15
2:38PM
439503

CANALES, Art
Christian
Evangelista
7/M/18kg

Bonzo

12/05/2007
Muntinlupa/LPC

DFS PCAP
moderate risk;
Anemia prob
sec to
hemolysis
infection vs
blood loss vs
IDA

PPI

Policar
Arca

Paracetamol 250mg/5ml (6ml) Q$


Salbutamol (Ventolin) Q6
Cefuroxime 500mg IV Q8 D3 9/4 12nn
Azithromycin 200/5 5ml OD D2 9/5 12nn
Paracetamol 170mg IV Q4 38.6
OMX gel 1 cap BID
Ferlin syrup 6 ml OD
D5 NM 1L x 55cc/hr

DISCHARGES (5)
302A
CAEZA, John Eris
9/1/15
F.
1:02PM
7/M/31.5kg
343497
Carrillo

306
8/29/15
6:45pm
609994

05/19/2008
Cavite

TUY, Marko Estefan


3/M/20kg
9/10/2011
Cabanatuan/LPC

Carrillo

Gen. Urticaria;
Multiple
Lesions
Hypersensitivity
reaction (Gen.
Urticarira) sec
to bacterial
infection

Acute
Bronchitis with
some
dehydration
Acute
Bronchitis

PPI

Anchores

Hydrocortisone 135mg IV q6
Diphenhydramine 25mg IM (single dose)
Mupirocin ointment TID
Cetirizine (Alnix) 5ml BID
Cetaphil lotion TID
D5 NM IL x 63 cc/hr

PPI

Anchores

Cefuroxime (Profurex) 750mg slow IV push


Q8 D6 9/3 12nnCefuroxime 250/5 5ml
q4
Cefuroxime 250mg/5ml; 5 ml q8
Metronidazole (Triconex) susp 125/5 10ml
TID D5 9/4 8am
Paracetamol (Tempra Forte) 5ml Q4 T37.8
Paracetamol 200mg IV q4
Salbutamol 1 nebule Q8
Zn SO4 syrup (Ezinc) 5ml OD
Calmoseptinecream PRN or 3-4x/day
Probiotic (Protexin restore) 1 sachet OD
D5 NM 1L x 63cc/hr (FM)

327B
9/1/15
11:40am
490094

CALAHATI, Paulyn
Nicole Sedaria
9/F/45kg
12/23/2005
Batangas

DFS DHF II

PP

Alcala/
Tugade

Paracetamol 250mg/5ml, 10ml Q4- 37.8


Omeprazole 40mg SIVP OD
OMX cap BID
Cetirizine oral syrup 5ml BID as necessary
for itchiness
Salbutamol 1 neb Q8

CBC 9/1: 4.08/.35/117/5.0/.71/.01/.26/.02/162


CBC 9/2 3.06/0.30/100/5.0/.59/.03/.34/.04/152
CBC 9/3 3.38/0.29/97/5.8/.54/.43/03.144
CBC 9/4: 3.38/.29/97/4.2/.54/--/.45/.01/180
CC: Fever
4 days PTA, (+) intermittent undocumented fever, w/
non productive cough and occ. Colds. Patient given
Paracetamol 250mg/5ml (5-7.5ml), noted temporary
relief.
2 days PTA, (+) fever TMax 39.0. Patient was
brought to ER CBC and urinalysis and DNS1 done.
UA w/ note of small amount of RBC.Patient requested
to return the next day for repeat CBC.
1 day PTA, mothe didnt bring the patient to the ER.
Morning PTA, patient brought to ER. CBC done
revealed plt count of 162, and was then admitted.

UA: ly/h/6.5/neg/neg/1.010/0-2/1-3/ec-occ/b-occ
NS1Ag: (-)
IgM: (-)
IgG: (-)
CXR (o) Interstitial Pneumonitis
PT: 13.2/12.0/88/126%
PTT: C- 32.7/ T-29.2
Peripheral Blood Smear: Normochromic, slightly
microcytic rbc with mild anisopoikilocytosis.
Platelets and wbc appear adequate in number with
slight predominance of lymphocytes. Few reactive
lymphpcytes seen. Few baskets cells are also
present. No primitivity noted.
Retics___________________________________
UA______________________________________
CXR_____________________________________

CBC 9/1: 4.98/.41/133/7.9/.58/.03/.33/.06/348

UA: ly/h/6.5/tr/neg/1.015/1-2/4-8/ec-few/b-few

CC: Multiple lesions/ Urticarial rashes


2 weeks PTA, (+) rashes with itchiness w/c started on
his neck,ears, cheeks and nose. No other
associated symptoms like fever, cough and colds.
11 days PTA, patient sought consult and was given
Triderm cream BID and Cetaphil wash. No relief
noted.
2 days PTA, patient had an uricarial rashes (patches)
on his lower extremities and noted his multiple lesions
with pus. Sought consult and was given Cloxacillin
5ml but didnt afford relief which prompted consult.
Hence this admission.

SE yellowbrown/soft/blood neg/mucus neg/


ovaparasite none seen/ yeast cells seen

CBC 8/29: 5.08/.42/140/20.8/.85/.01/.09/.05/344


CBC 9/24.27/0.35/119/13.2/.57/.02/.31/0.10/.02/.39

UA:dy/h/6.0/tr/-/1.025/3-4/4-8/occ
SE:yb/m/-gb/pc-2-4/m+/EHCseen/rbc1-2
ChesXray (o): Normal

CC: Fever
9 days PTA, patient had non productive cough.
Broncaire expectorant was given but no relief.
7 days PTA, patient still with on-off non productive
cough accompanied with colds.
3 days PTA, patient had fever T 39.9. Paracetamol
(Tempra) 5ml but only had slight decrease in
temperature.
2 days PTA, patient still with fever T 37.8. Sought
consult and was given Amoxiclav 5ml BID,
Salbutamol TID, andAllerkid 5ml OD.
3 hours PTA, patient still with fever T 40C.
Paracetamol given. Persistence of fever prompted
consult. Hence this admission.
CBC 9/1 am: 5.20/.43/141/6.5/.70/.01/.17/.12/172
CBC 9/1: 4.70/.39/129/5.2/.43/.01/.52/.04/136
CBC 9/2 6am 4.66/.39/129/4.3/.40/.02/.48/.10/132
CBC 9/2 6pm 5.12/.43/140/5.5/.39/.02/.47/.12/124
CBC 9/3 6am 4.69/.39/130/5.7/.48/.03/.37/.12/144
CBC 9/4 6am 4.69/.39/129/6.0/.48/.05/.36/.11/171

NS1 Ag neg, IgM pos, IgG pos


PT 9/1: C-13.2; T-11.3; 0.81; 148%
PTT 9/1: 37.0; 29.2
UA:____________________________________
PT 9/2 13.2/10.9/0.78.164%
PTT 9/2 38.7/29.2

CC: Nose bleeding

CXR AP (o): NCATS

Bonzo
D5 LR 1L x 135cc/hr113 cc/hr
5 days PTA, patient started to have fever tmax 40C
with associated productive cough with whitish
sputum, colds, and decrease in appetite. No note of
vomiting or difficulty of breathing. Patient given
Paracetamol 250mg/5ml 10ml which afforded
temporary relief. No consult done.
4days PTA, above symptoms persisted. No consult
done.
3 days PTA, upon waking up noted no fever. Fever
recurred night that day. Paracetamol continued.
2 days PTA, above symptoms persisted. No consult
done.
1 day PTA, at morning, sought consult due to fever
persistence. At night, there was an episode of
epistaxis, L nasal cavity which lasted for <10mins.
Patient was brought to the ER and eventually sent
home improved. Patient also complained of

357
8/31/2015
8:08 pm
414406

REPRE, Von Louis


L.
4/M/14kg

Pneumonia
Pneumonia
Moderate Risk

PPI

Principe

Cefuroxime 467 mg IV Q8 ANST (-)


Paracetamol 250/5 3 ml q4 PRN for T>
37.8 C
Salbutamol + Ipratropium (Combivent) 1
neb Q30 Q4

12/06/2010
LPC
Binos

D5 IMB 500cc x 40 ugtts/min D5 IMB


500cc x 50 ugtts/min
CVU13-B
9/3/2015
3:41 pm
610317
Bonzo

CASTANEDA,
JosaiahSedwick S.
7/M/24kg
07/18/2008
LPC

AGE with
moderate
dehydration r/o
intestinal
amoebiasis
AGE with mod
dhn

PP

Suratos
Teves/
Bumanlag

Paracetamol 250/5 5ml q4 T>37.8


Paracetamol 240mg IV q4 T >39
Erceflora vial BID (c/o px)
Zinc syrup 5ml OD
D5 LR 240cc fast drip then regulate @
90cc/hr (30/8) D5 NM 1Lx 10 hours

abdominal pain, sharp stabbing in the umbilical area,


nonradiating, intermittent. No note of joint or muscle
pain.
Morning PTA, had another epistaxis and mother
noted appearance of diffused rashes all over her
body. Patient afterwards brought to ER and
subsequently admitted.
CBC:4.90/0.38/128/9.4/0.23/0.09/0.54/0.09/321
CC: cough
2 days PTA, (+) non-productive cough, (+) good
appetite. No fever, (-) colds, (-) abdominal pain, (-)
rashes. Alnix 5 ml given.
1 days PTA, now with fever (Tmax 38.5C), (+) labored
breathing, 1x vomit. Paracetamol 250/5 5ml given.
Morning PTA, (+) retractions, persistence of
symptoms, hence admitted.
CBC 9/3 4.25/.36/112/12.3/.87/.01/.09/.03/346
CC: LBM
2 daysPTA, patient started to experience watery soft
stools 2x, with associated 2 episodes of nonbilous
vomiting. No medications given nor consult done.
1 day PTA, patient had persistence of now loose
watery stools, 7x, with associated 3x vomiting of non
bilous material. There was also note of decrease in
appetite, hence patient brought to another institution,
and was subsequently transferred in our institution
and was then admitted.

CXR APL (0): interstitial Pneumonia

UA y/h/6.0/neg/+3/1.025/0-2/2-3/rare/few
FA y/w/-/1-2/-/none seen/0-2 hpf/fat globules seen
Na 133 dec
K 3.1 dec
Cl 100 N

Вам также может понравиться