November 29, 2009
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Date of admission
Diet: 1500 kcal/kg (270g CHO, 70g CHON, 50g fats)/3 meals
VS, input and output monitored
IVF 1L PNSS administered
Labs requested: CXR, CBC, pH, blood C&S, ABG, sputum GS, BUN, Crea, Na/K, Urinalysis: proceed
with C&S if PMN > 25 cells/hpf or sq cells <10 cells/hpf
Medications:
o Ceftriaxone 2g/IV first dose given now then OD
o Azithromycin 500mg/tab 1 tab given now then OD x 5 days
o Erdosteine 300mg/cap 1 cap BID
o Combivent nebulization q 8 hrs
o Paracetamol 500mg/tab 1 tab q 4 hrs prn for T>38C
O2 via nasal cannula
Admitting diagnosis: Parapneumonic effusion R; JRA
November 30, 2009
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1:25am
o Start Kalium durule, 1 durule QID
o Request for TPAG
o For serial abdominal measurement and weighing of patient daily pre-breakfast
8:40am
o Kalium durule 1 durule TID x 8 doses
o Repeat K+ after last dose of KCl durule
Referral to Rheuma
8:50pm (Pulmo): Problem – Febrile 40C
o Increase IVF rate to 50 drops/min for 4 hrs then decrease to 30 drops/min thereafter
o Give Paracetamol 500mg/tab, 1 tab q 4 hrs round the clock
o May do ice bath care of relatives
December 1, 2009
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1:05am (Pulmo)
o Decrease IVF to 30 drops/min
o Nebulize with Combivent nebule now then q 4 hrs
o Maintain O2 supplementation
1:25am: Problem – Persistently febrile
o Continue with ice bath
o Shift oral Paracetamol to Paracetamol 300mg/IV q 4 hrs round the clock
8:50am (Pulmo)
o Problem – Parapneumonic effusion, R
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 Day 2 Ceftriaxone and Azithromycin
 Azithromycin to complete 3 days
 O2 supplementation prn
Problem: Hypoalbuminemia
 Add 2 eggwhites/meal
 Request for SGPT and SGOT
Problem: Anemia
 Request for reticulocyte count and peripheral smear
Problem: Persistently febrile
 Continue Paracetamol 300mg/IV round the clock
 Continue TSB
Problem: Hypokalemia, on correction
 Increase K+ in diet
 Continue Kalium durule
Addendum: Request for blood CS
o
4:05pm
o Problem: HAP and parapneumonic effusion, R
 Shift Ceftriaxone to Piperacillin-Tazobactam 4.5g/IV q 8 hrs
December 2, 2009
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10am: Rheumatology
o Diagnosed case of JRA
11am: Rheumatology
o Naproxen 250mg 1 tab OD
6:20pm
o Schedule for Thoracentesis at 10:30am the next day (UTZ-guided) this wasn’t done
though cause the meds worked…tanggalin na ba ‘to?
o Request for UTZ and PTPA
10:45pm: Problem – PT=15.8 secs
o Start Vitamin K 10mg/IV q 8 hrs
December 03, 2009
Rheumatology
 Arthralgia
 Still with febrile episodes; denies arthralgia
 BWJ To S1W1 ; BAJ T0S1, W0
 Request for Repeat CBC
December 04, 2009
 Awaiting final report of Blood C and S
 Relay of Repeat CBC results of Dec.03,2009
 Problem  Hypoalbuminemia
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May have Peptamen 3 scoops /meal
Problem  Abdominal Enlargement
Request for Ultrasound of LGBPS
NPO 6 hours prior to procedure
Rheumatology
 Suggest Repeat Chest X-ray (PA and Lateral View)
 Suggest Infectious Disease referral
Infectious Disease:
 P-test says “Scant”
 Management:
 Repeat Chest X-ray PA/Lateral
 Pip – Tazo
 Await for blood cultures
December 05, 2009
Rheumatology
 Burholderia cepacia
December 06, 2009
Pulmonology
 Repeat Na and K
 Decrease nebulization
December 07, 2009
Rheumatology
 Discontinue nebulization.
Infectious Disease
 Start Anti –TB medications.
November 30, 2009
 Empiric Antibiotic instituted (Ceftazidime – 2g for 7 days); Clinical Diagnosis: CAN’T READ IT!!!
Fever Pattern:
 November 30, 2009 – 37-39 degrees, PR: 140-150, RR: 33-40, BP: 90/60-100/60, Pain Score: 0 on
rest and activity, urine: 9x, stool- 2x, Activity: Person-assisted
 December 01, 2009 – 37-38.5 degrees, PR: 110-150, RR: 30-37, BP: 100/60 – 120/80, Pain Score: 0
on rest and activity, urine: 9x, stool- 3x, Activity: Person-assisted
 December 02, 2009 – 37-37.5 degrees, PR: 110-150, RR: 30-40, BP: 100/60, Pain Score: 0 on rest and
activity, urine: 12x, stool- 5x, Activity: Person-assisted
 December 03, 2009 – 36.5-37.5 degrees, PR: 80-110, RR: 31-38, BP: 100/60-110/70, Pain Score: 0 on
rest and activity, urine: 10x, stool- none, Activity: Person-assisted
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December 04, 2009 – 36.5-37 degrees, PR: 85-150, RR: 32-40, BP: 90/60-100/60, Pain Score: 0 on
rest and activity, urine: 13x, stool- 2x, Activity: Person-assisted
December 05, 2009 –36.5-37, PR: 85-115, RR: 21-40, BP: 100/60-110/70, Pain Score: 0 on rest and
activity, urine: 5x, stool- 1x, Activity: Person-assisted
December 06, 2009 – 37.5 – 38 degrees, PR: 80-90, RR: 20-31, BP: 110/70-120/70, Pain Score: 0 on
rest and activity, urine: 8x, stool- 3x, Activity: Person-assisted
December 07, 2009 – 36.5 - 38 degree, RR: 20-24, BP: 100/60-120/80, Pain Score: 0 on rest and
activity, urine: 5x, stool- 2x, Activity: Person-assisted
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Blood C and S:
 December 04, 2009
 Culture: Burkholderia cepacia
 Sensitive to TMP-Sulfamethoxazole
Blood Chemistry:
 December 01, 2009
o SGOT –AST: 40.9 (High)
o SGPT – ALT: 12.0 (Normal)
CBC:
 December 01, 2009
o Reticulocyte Count: 1.0 x 10^3
o WBC: No abnormal
o RBC: Normocytic Normochromic
o Platelet: Increased
Fecalysis
 November 30, 2009
o Yeast Cell - +3
DIET/MEDICATIONS ON ADMISSION
DATE ORDERED
DIET
11/29/09
1500 kcal/kg 270g CHO 70g CHON 50g fats / 3m +
2s
DATE
MEDICATIONS/TREATMENTS
FREQUENCY
DATE STARTED
11/29/09
11/29/09
Ceftriaxone 2g/IV
Azithromycin 500mg/tab 1
tab x 5 days
Erdosteine 300mg/1 cap 1
cap
Paracetamol 500mg/1 tab 1
OD
OD
11/29/09
11/29/09
BID
11/30/09
q4 prn
T=38C
11/29/09
11/29/09
DATE
DISCONTINUED
11/30/09
11/30/09
12/4/09
tab
KCl durule 1 durule x 8
Paracetamol 500mg/tab 1
tab
Paracetamol 300mg/IV
TID
q4 RTC
11/30/09
q4
12/1/09
12/1/09 (shifted)
Date & time: Nov 29, 2009 5pm
ECG RESULTS
Rhythm: Sinus
Atrial rate: 115/min
Ventricular rate: 115/min
PR: 0.12 sec
QRS: 0.12 sec
QTC: 0.30 sec
QRS axis: Indeterminate axis
ELECTROCARDIOGRAPHIC DIAGNOSIS
1. Sinus tachycardia
2. Complete right bundle branch block
3. Low voltage chest leads
Date & time printed: Nov 29, 2009 6:32pm
Urinalysis
PHYSICAL
CHARACTERISTICS
Color
Transparency
pH
Specific Gravity
CHEMICAL TEST
Albumin
YELLOW
SLIGHTLY TURBID
9.0
1.015
Sugar
MICROSCOPIC
FINDINGS
NEGATIVE
NEGATIVE
MICROSCOPIC
FINDINGS
CELLS
Red Blood Cell
Pus Cell
Yeast Cell
Squamous Cell
Renal Cell
Transitional
Epithelial Cell
Bacteria
Mucus Threads
0-1/hpf
2-5/hpf
+
+
CAST
Hyaline
CRYSTALS
Amorphous
Urate
Uric Acid
Calcium Oxalate
Amorphous
Phosphate
Triple Phosphate
Granular
Waxy
Pus Cell
Red Blood Cell
Date & time printed: Nov 29, 2009 7:35pm
Blood Chemistry
Test
Sodium
Potassium
Result
Female Reference Range
135 (low) 137-147 mmol/L
3.2 (low) 3.8-5 mmol/L
Date & time printed: Nov 29, 2009 7:47pm
COMPLETE BLOOD
COUNT
HGB
RBC
HCT
MCV
MCH
MCHC
RDW
MPV
PLATELET
WBC
DIFFERENTIAL COUNT
NEUTROPHILS
METAMYELOCYTES
BANDS
SEGMENTED
LYMPHOCYTES
MONOCYTES
EOSINOPHILS
BASOPHILS
RESULT
UNIT
REFERENCE RANGE
101
3.56
0.30
84.20
28.40
33.80
14.80
6.20
437
19.80
g/L
x 10^12/L
120-170
4.0-6.0
0.37-0.54
87+-5
29+-2
34+-2
11.6-14.6
7.4-10.4
150-450
4.5-10.0
0.93
0.03
0.90
0.07
-
Date & time printed: Nov 30, 2009 7:10am
Blood Chemistry
U^3
pg
g/dL
fL
X 10^9/L
X 10^9/L
0.50-0.70
0.00-0.05
0.50-0.70
0.20-0.40
0.00-0.07
0.00-0.05
0.00-0.01
Test
Urea Nitrogen
Creatinine
Total Protein
Albumin
Globulin
A/G Ratio
Result
4.1 (low)
0.48 (low)
6.1
2.7 (low)
3.4
0.80 (low)
Female Reference Range
9-23 mg/dL
0.5-1.2 mg/dL
6-7.8 g/dL
4-5.5 g/dL
1.5-3.4 g/dL
1-3
Date: Dec 3, 2009
Ultrasound of the right hemithorax shows a pleural effusion with an approximate volume of 51.4cc.
Date: Dec 5, 2009
ULTRASOUND OF THE LIVER, GALL BLADDER, PANCREAS AND SPLEEN
The liver is within normal range in size with non-uniform echogenicity. No focal echo defect seen. Ducts
are not dilated.
The gall bladder measures 4.4x1.9cm. in size which is within normal range. A high level echo is noted
intraluminally exhibiting acoustic shadowing. Wall is not thickened.
The pancreatic head is 2.1cm. while the body is 1.1cm. and the tail is 1.3 cm. which are all within normal
range. Echo pattern is uniform. Negative for mass in or at the region of the pancreas.
The spleen is not enlarged. Negative for intra-splenic mass.
IMPRESSION:
NORMAL SIZE LIVER WITH DIFFUSE PARENCHYMAL CHANGES
CHOLECYSTOLITHIASIS
PANCREAS AND SPLEEN – NEGATIVE