general data
DESCRIPTION
General Data. RP 2 months/Male Manggahan ,QC Catholic. Chief complaint. “LBM”. History of Present Illness. History of Present Illness. ROS. No cough, no colds, no difficulty of breathing No cyanosis,no pallor No pruritus , no easy bruising , no rash No lymph node enlargement - PowerPoint PPT PresentationTRANSCRIPT
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General Data
• RP• 2 months/Male• Manggahan ,QC• Catholic
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Chief complaint
“LBM”
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History of Present Illness
3 daysPTA
•(+) watery stools, 5x diaper change, half full/diaper•(+) undocumented fever•(-) meds given•(-) consultation was done
2 days PTA
•(+) watery stool, same character, 4x•(+) vomiting, post feeding•(+) fever (TMAX 39)•(+) consult: unrecalled diagnosis, unrecalled
medications
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History of Present Illness
Day of consultation
•(+) watery stool, 4 episodes of diaper change, half full,(-) vomiting
•Consulted at EAMC•THOC to PCMC•Last UO: 11 am (13hours prior)
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ROSNo cough, no colds, no difficulty of breathingNo cyanosis,no pallorNo pruritus, no easy bruising, no rashNo lymph node enlargementNo doubling of visionNo ear dischargeNo bleeding gumsNo convulsion
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Family Medical History
• (-) DM• (-) HPN• (-) Asthma• (-) PTB• (-)Malignancies
43 33
Twin A2 months
Twin B2 months
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Birth and maternal history
• 33 years old G1P2(1002), non smoker, non alcoholic beverage drinker
• RPNCU at LHC, midwife at 2 months AOG.• (+) URTI for 3 weeks-No medications. No consult.• (+) intake of MVT, and FeS04• UTZ at 7 and 9 months: Normal • No noted UTI, HPN, DM• Denies intake of abortifacient• No exposure to viral exanthem and radiation
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Birth and maternal history
• Fullterm via CS at Fabella hospital• (+) Good cry and activity• (-) cord coil, (-) MSAF, (-) PROM• Birth weight was unrecalled• No newborn screening done• Pt was immediately roomed in • Given unrecalled Antibiotics for 5 days
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Feeding history
• Bottle fed with Nestogen with dilution of 1:1 and consumes 3 oz every 3 hours
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Immunization history
• 1 BCG• 1 Hepa B• 1 DPT
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Growth and developement
• Smiles at 2 months• Follows objects past midline• vocalizes
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Personal and Social History
• Lives with 3 household members in a well lit well ventilated house
• Garbage collected everyday• Water for consumption is purified water
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Past medical history
• No history of previous admissions• No history of allergies to foods and
medications
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Physical examinationWeak looking
CR 130 RR 20 T 37 BP 80/50
Weight 3.5 kg (-3) Length 53 cm (-3)
Sunken anterior fontanelle, sunken eyeballsPink palpebral conjunctiva, anicteric sclera,(-) alar
flaring, dry lips, dry mucosa(-)Intercostal and subcostal retractions, symmetrical
chest expansion, Clear Breath sounds
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Physical examination
Adynamic precordium, Normal rate, regular rhythm, no murmur
Globular, normoactive bowel sounds, soft, no mass, no organomegaly
Dry skin ,No cyanosis, no edema, full pulses, warm extremities, CRT <2 sec
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Assessment
Acute gastroenteritis with severe dehydration
R/O sepsis
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Course at the ERA P
5/17/1412:00AM
CC: LBMSunken eyeballs Sunken anterior fontanelle(-) Urine output for 12 hours
Hgt 143For CBC and serum electrolytes 4 hours of hydrationStool ExamBlood CS
AGE with severe signs of dehydration R/O sepsisSeverely underweight,severely stuntedwasted
PNSS 10cc/kilo for 1 hour then30ml/kilo for 1 hour then70ml/kilo for 5 hours Reassess every 1-2 hoursAmpicillinGentamicin
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A P
5/17/146:30 AM
Input : 390ccOutput: 60ccUO: 2.9 cc/k/hr for 6 hours
Sunken eyeballsSunken anterior fontanelleCBSFull pulses
90/6013036.1
CXR APL post hydrationCBC:Hbg: 85Hct: 0.25Plt: 670WBC: 24.9Seg: 0.60Lympho: 0.40
Na: 137K: 3.70Cl: 115Ca: 2.25
AGE with severe signs of dehydration R/O sepsisSeverely underweight,severely stuntedwasted
D5LR 30ml/k for 1 hourThen D5LR 70ml/k for 6 hoursReassess after 1-2 hoursWOF: gurgly chest, desaturation,cyanosis
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A P
5/17/149:00 AM
(-) VomitingDecrease amount of watery stool(+) respiratory distressAsleep ComfortableSunken anterior fontanelleNon sunken eyeballs(+) blood clots on the tongue and hard palateSlightly dry lipsClear breath sounds
PT, PTTABG
SepsisAGE with severe signs of dehydration Severely underweight,severely stuntedwasted
NPO temporarilyHgt now then q8
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5/17/1410:10AM
pH: 7.08PCO2: 11PO2: 105SO2: 95%HCO3: 3.3Beb: -24.5
PTPt: 11.5Ctr: 11.2%act: 94.3 %INR: 1.03
PTTPt: 38.7Ctr: 28.3
SepsisAGE with severe signs of dehydration Severely underweight,severely stuntedwasted
NaHCO3 drip (0.3)Repeat ABG 1 hr post correction
Refer to PIDSPlan to shift Gentamycin to Cefotaxime
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A P
5/17/1412:10 PM
02 sat: 90 at 10lpm(+) puffy eyelids(+) SC and IC retractions(+) Blood clots per oremSlightly dry lipsGood air entry(-) wheezingFull pulsesWarm extremitiesUO: 228ml in 4 hours (admixed with stoolsBP 80/50CR 171RR 70
ABG 1 hour post correctionCXR post intubationFor CUTZFor stool culture
Respiratory FailureSepsis t/c DICAGE with severe signs of dehydration Severely underweight,severely stuntedwasted
Intubate pt size 4 level 11.5RSID5LR (2x MTN)NaHCO3 7 meqs (2meqs)Inc. Ampicillin to (200)Refer to RICU
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A P
5/17/141:00 PM
RICU notesIntubated on CABBP: 80/50CR: 150(-) tearsSlightly sunken anterio fontanelle(+) puffy eyelidsSlightly dry lipsMoist buccal mucosa(+) blood tinge ET secretionsGood skin turgor(+) suprasternal retractionWarm ext. FEP
UrinalysisStool examStool CSBlood CSTPAGTACS TAGSBUNCreaALTAST
Respiratory Failure secondary to severe metabolic acidosis secondary to GI losses
Dec IVF: D5LR (1.5x MTN)Omeprazole (1)
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A P
5/17/142:40 PM
PIDS notesActivePuffy eyelidsSoft abdomen
AGE with severe dehydration
Facilitate blood CSContinue Ampicillin and Gentamicin
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A P
5/17/143:05 PM
RICU notesBP: 80/50CR: 130RR: CAB02 Sat: 98Open anterior fontanelleSlightly puffy eyelidsPink conjuctivaAnicteric sclera(+) Bleeding ET tube(+) subcostal retractionsHarsh breath soundsAP, tachycardic (-) murmurGlobular abdomen,(-) organomegalyFull and equal pulsesWarm extremitiesCRT < 2 secs
For PBSRetic countCoombs test
Respiratory Failure secondary to severe metabolic acidosis secondary to AGESepsis
Admit to RICUHook to MVContinue present medicationsIVF: D5LR (1.5x MTN)Prepare PRBC 1 unit divided into 3 aliqs for transfusion
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A P5/17/144:00 PM
BP 0CR 130Poor pulses(+) Bleeding ET tube
4:03 PmBP UnappreciatedPoor pulsesPupils sluggishly reactive to light
4:06 PMBP unappreciatedPoor pulsesPupils sluggishly reactive to light
DICSeptic shock Respiratory FailureAGE with severe signs of dehydration Severely underweight,severely stuntedwasted
PNSS 20cc/kiloDopamine (10mckm)
Give another 20cc/kilo
Give another 20cc/kiloStart dobutamine (10mc/k/m)
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A P
5/17/144:10
BP 0CR 0Pupils non reactivePulses unappreciated
4:20 PM
BP 0CR 0
DICSeptic shock Respiratory FailureAGE with severe signs of dehydration Severely underweight,severely stuntedwasted
Start CPRVoluven 10cc/kiloEpinephrine (0.1)
Prenounced deadEpinephrine (5doses)
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Mortality diagnosis
• DIC• Septic shock • Respiratory Failure• AGE with severe signs of dehydration • Severely underweight,severely stunted• wasted