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General Data

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

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General Data

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  1. General Data • RP • 2 months/Male • Manggahan ,QC • Catholic

  2. Chief complaint “LBM”

  3. History of Present Illness

  4. History of Present Illness

  5. ROS • No cough, no colds, no difficulty of breathing • No cyanosis,no pallor • No pruritus, no easy bruising, no rash • No lymph node enlargement • No doubling of vision • No ear discharge • No bleeding gums • No convulsion

  6. Family Medical History (-) DM (-) HPN (-) Asthma (-) PTB (-)Malignancies 43 33 Twin A 2 months Twin B 2 months

  7. 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

  8. Birth and maternal history • Fulltermvia CS at Fabellahospital • (+) 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

  9. Feeding history • Bottle fed with Nestogen with dilution of 1:1 and consumes 3 oz every 3 hours

  10. Immunization history • 1 BCG • 1 Hepa B • 1 DPT

  11. Growth and developement • Smiles at 2 months • Follows objects past midline • vocalizes

  12. 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

  13. Past medical history • No history of previous admissions • No history of allergies to foods and medications

  14. Physical examination Weak looking CR 130 RR 20 T 37 BP 80/50 Weight 3.5 kg (-3) Length 53 cm (-3) Sunken anterior fontanelle, sunken eyeballs Pink palpebral conjunctiva, anicteric sclera,(-) alar flaring, dry lips, dry mucosa (-)Intercostal and subcostal retractions, symmetrical chest expansion, Clear Breath sounds

  15. Physical examination Adynamicprecordium, 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

  16. Assessment Acute gastroenteritis with severe dehydration R/O sepsis

  17. Course at the ER

  18. Mortality diagnosis • DIC • Septic shock • Respiratory Failure • AGE with severe signs of dehydration • Severely underweight,severely stunted • wasted

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