CEBU (VELEZ) GENERAL HOSPITAL DEPARTMENT OF PEDIATRICS Cebu City

DISCHARGE SUMMARY
P()IE*)+, *(-E )ABC*.6, %ylvestre ?lint Cadungog DI(G*3,I, (GE 2 months ,E. ,)()/, C2ild C(,E */-0E1 #"92#8#, #"388-

1. Pneumonia -oderate 1isk D()E *5(

3PE1()I3* PE1431-ED *5(

PROBLEM: Pneumonia moderate risk S: 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 ! of previously ingested milk amounting to "##cc per episode. No diarrhea, anore!ia, retractions nor dyspnea mentioned. $e was given %albutamol &A'(A)*N+ mg,-m) .- m) &A./#." mkd+ and Phenylpropanolamine $cl 0 1rompheniramine (aleate &Nasatapp+ 2. -mg, mg,m) #.2 m) &A./#.34mkd+ which provided temporary relief of symptoms. 5 hours PTA, cough and fever still persisted associated with dyspnea and cyanosis thus prompting admission.
O: 6n admission, patient was e!amined conscious, awake, alert, afebrile, not in respiratory distress, with the ff vital

signs7 HR: "2#bpm RR: 82cpm Temp: 54.4 C,a!illa Wt: 4.4 kg &zscore7 # %.+ Ht: 29.-cm &zscore7 :" %.+ HC: 95 cm &zscore7 # %.+ BMI: "8.- kg,m &zscore7 below 0 %.+ Skin: warm, dry, fair skin, no gross lesions, no rashes, good skin turgor and mobility con;unctivae, &:+ tug test, nasal septum midline Neck: short, supple, trachea at midline, no lymphadenopathy C/L: CVS: Abd: GUT: e<ual chest e!pansion, resonant, harsh breath sounds, &0+ rales adynamic precordium, %" and % distinct, normal rate, regular rhythm, &:+ murmurs globular, no rashes, umbilicus at midline, normoactive bowel sounds, &:+ mass, &:+ tenderness. bladder not distended, grossly male

HEENT: normocephalic, eyes not sunken, anicteric sclerae, pink palpebral con;unctivae, &0+ nasal discharges

Extremitie : no gross deformity, full range of motion all e!tremities, strong peripheral pulses, no edema, C'T of = seconds CNS: CN I: Cerebr!": awake and alert cannot be assessed SIGNATURE OF AP Ellen Gasendo .r. Dr. >ean ?rancis ?lores : i! "# 90$$% Alcantara )icense @7 2-"84 Cr!ni!" Ner#e : CN II$ III: &0+ P)', direct and consensual, both eyes & mm, mm+ ADMISSION DISCHARGE CONDITION IN-PATIENT DATE DATE DISCHARGED DAYS 4 9 2014 4 12 2014 Improved 4 PREPARED BY: PIIC &ane ou E. Gar'aritano RESIDENT-IN-CHARGE: .r. %erah %aphira Allera )ic @7 #" 988-

CN III$ IV$ VI: CN V: CN VII:

full e!traocular movements good suck symmetrical facial e!pressions

CN VIII: CN I%$ %: CN %I: CN %II: Sen &r': M&t&r:

turns to the source of sound, hearing intact &0+ gag refle! symmetrical shoulders tongue midline on protrusion arouses with painful stimuli good muscle tone, no atrophy

Cerebe""!r: no nystagmus M&t&r: no tremors, no atrophy, no fasciculations

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C(URSE IN THE WAR): 6n admission, patient was afebrile, not in respiratory distress with stable vital signs. Chest Dray was taken and revealed radiologic findings of Pneumonia in the left lower lung. Cefuro!ime &Einacef+ -#mg *FTT " st dose was given over 5# minutes as *F drip then continued as *FTT every 8 hours. %albutamol " nebule ordered to be given via nebulization every 2 hours and Paracetamol "##mg,m) " m) &A./" .33 mkd+ ordered to be given orally every 9 hours. *F? was started with .- #.5 NaCl at 5 cc,hr as maintenance fluid. *nput and output monitored every shift with vital signs monitoring every hours. 6n 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. C1C was taken and result showed increased leukocyte count with monocytic predominance &G1C H "5.5I (onophils H "#.9J+ and anemia &$gb H ""." g,d)I $ct H 5-.#JI (CF H 4 .4JI (C$ H 5." pgI '.G H "".5J+. Platelet count was normal & 99+. (edications were continued. 6n the nd hospital day, vital signs are stable. No dyspnea, afebrile, no bleeding diathesi s noted. Patient was started with chemotherapy with Cytarabine 52 mg *F push <" h for # doses in "# days and .o!orubucin "8 mg *F drip in -# ml of .-water to run for " hour using microset given every other day for 5 days. Patient then monitored for any allergic reactions. 6n the 5rd 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 "#mg,m) drops #. m) 6. every night was prescribed and given with relief. (onitored every hours. Patient stable and may go home instructions given. *F? discontinued prior to discharge. Patient discharged improved. *: ". . Take home medications7 Cefuro!ime -#mg,-m) m) &A./" .38 mkd+ 1*. for 4 days &8am : 2pm+ %albutamol &Fentolin+ " neb T*. for 5 days &4am:5pm:""pm+

To come back for follow up check up at .r. AlcantaraKs clinic on April "2, #"9