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