Post on 20-May-2017
CEBU (VELEZ) GENERAL HOSPITALDEPARTMENT OF PEDIATRICS
Cebu City
DISCHARGE SUMMARY
PROBLEM: Pneumonia – moderate riskS: About one week PTA, patient had onset of non productive cough and coryza. No fever, dyspnea nor cyanosis. Condition was tolerated, no treatment given. Two days PTA, patient had productive cough with tenacious sputum, non bloody and non foul smelling, amounting to one spoonful associated with fever, coryza and vomiting 2x of previously ingested milk amounting to 100cc per episode. No diarrhea, anorexia, retractions nor dyspnea mentioned. He was given Salbutamol (ARMALIN) 2mg/5mL 2.5 mL (AD=0.12mkd) and Phenylpropanolamine Hcl + Brompheniramine Maleate (Nasatapp) 6.25mg/2mg/mL 0.6 mL (AD=0.97mkd) which provided temporary relief of symptoms.
3 hours PTA, cough and fever still persisted associated with dyspnea and cyanosis thus prompting admission.
O: On admission, patient was examined conscious, awake, alert, afebrile, not in respiratory distress, with the ff vital signs:
HR: 160bpm RR: 86cpm Temp: 37.7 C/axilla Wt: 7.7 kg (zscore: 0 SD) Ht: 64.5cm (zscore: -1 SD)
HC: 43 cm (zscore: 0 SD) BMI: 18.5 kg/m2 (zscore: below +2 SD)
Skin: warm, dry, fair skin, no gross lesions, no rashes, good skin turgor and mobility
HEENT: normocephalic, eyes not sunken, anicteric sclerae, pink palpebral conjunctivae, (+) nasal discharges
conjunctivae, (-) tug test, nasal septum midline
Neck: short, supple, trachea at midline, no lymphadenopathy
C/L: equal chest expansion, resonant, harsh breath sounds, (+) rales
CVS: adynamic precordium, S1 and S2 distinct, normal rate, regular rhythm, (-) murmurs
Abd: globular, no rashes, umbilicus at midline, normoactive bowel sounds, (-) mass, (-) tenderness.
GUT: bladder not distended, grossly male
Extremities: no gross deformity, full range of motion all extremities, strong peripheral pulses, no edema, CRT of < 2 seconds
CNS: Cerebral: awake and alert
Cranial Nerves:
CN I: cannot be assessed
CN II, III: (+) PLR, direct and consensual, both eyes (2mm/2mm)
ADMISSION DATE
DISCHARGE DATE
CONDITION DISCHARGED
IN-PATIENT DAYS
SIGNATURE OF AP
4 9 2014 4 12 2014 Improved 4Dr. Ellen Gasendo
Lic #: 90336PREPARED BY: Dr. Jean Francis Flores -
AlcantaraPIIC Jane Lou E. Gargaritano License #: 65187
RESIDENT-IN-CHARGE:Dr. Serah Saphira Allera
Lic #: 0124885
PATIENT’S NAME AGE SEX STATUS
CASE NUMBER
LEQUIDO, Sylvestre Flint Cadungog 6 months M Child 20146080/ 019885
DIAGNOSIS 1. Pneumonia Moderate Risk
OPERATION PERFORMED DATE N/A N/A
CN III, IV, VI: full extraocular movements
CN V: good suck
CN VII: symmetrical facial expressions
CN VIII: turns to the source of sound, hearing intact
CN IX, X: (+) gag reflex
CN XI: symmetrical shoulders
CN XII: tongue midline on protrusion
Sensory: arouses with painful stimuli
Motor: good muscle tone, no atrophy
Cerebellar: no nystagmus
Motor: no tremors, no atrophy, no fasciculations
Reflexes:
COURSE IN THE WARD:
On admission, patient was afebrile, not in respiratory distress with stable vital signs. Chest Xray was taken and revealed radiologic findings of Pneumonia in the left lower lung. Cefuroxime (Zinacef) 250mg IVTT 1st dose was given over 30 minutes as IV drip then continued as IVTT every 8 hours. Salbutamol 1 nebule ordered to be given via nebulization every 6 hours and Paracetamol 100mg/mL 1 mL (AD=12.99 mkd) ordered to be given orally every 4 hours. IVF was started with D5 0.3 NaCl at 32 cc/hr as maintenance fluid. Input and output monitored every shift with vital signs monitoring every 2 hours.
On the first hospital day, patient was comfortable, afebrile with stable vital signs. No dyspnea, no cyanosis and had a good appetite. Patient still with cough and nasal discharges. CBC was taken and result showed increased leukocyte count with monocytic predominance (WBC – 13.3; Monophils – 10.4%) and anemia (Hgb – 11.1 g/dL; Hct – 35.0%; MCV – 72.7%; MCH – 23.1 pg; RDW – 11.3%). Platelet count was normal (244). Medications were continued.
On the 2nd hospital day, vital signs are stable. No dyspnea, afebrile, no bleeding diathesi s noted. Patient was started with chemotherapy with Cytarabine 36 mg IV push q12h for 20 doses in 10 days and Doxorubucin 18 mg IV drip in 50 ml of D5water to run for 1 hour using microset given every other day for 3 days. Patient then monitored for any allergic reactions.
On the 3rd hospital , vital signs were stable. Patient was able to sleep well and was afebrile throughout the night. No episodes of vomiting nor diarrhea. Patient had onset of generalized maculopapular rashes due to skin contact with bed linens. Cetirizine 10mg/mL drops 0.2 mL OD every night was prescribed and given with relief. Monitored every 2 hours. Patient stable and may go home instructions given. IVF discontinued prior to discharge. Patient discharged improved.
P: Take home medications:
1. Cefuroxime 250mg/5mL 2mL (AD=12.98 mkd) BID for 7 days (8am - 6pm)2. Salbutamol (Ventolin) 1 neb TID for 3 days (7am-3pm-11pm)
To come back for follow up check up at Dr. Alcantara's clinic on April 16, 2014