General Data

• RP• 2 months/Male• Manggahan ,QC• Catholic

Chief complaint

“LBM”

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

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)

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

Family Medical History

• (-) DM• (-) HPN• (-) Asthma• (-) PTB• (-)Malignancies

43 33

Twin A2 months

Twin B2 months

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

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

Feeding history

• Bottle fed with Nestogen with dilution of 1:1 and consumes 3 oz every 3 hours

Immunization history

• 1 BCG• 1 Hepa B• 1 DPT

Growth and developement

• Smiles at 2 months• Follows objects past midline• vocalizes

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

Past medical history

• No history of previous admissions• No history of allergies to foods and

medications

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

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

Assessment

Acute gastroenteritis with severe dehydration

R/O sepsis

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

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

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

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

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

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)

A P

5/17/142:40 PM

PIDS notesActivePuffy eyelidsSoft abdomen

AGE with severe dehydration

Facilitate blood CSContinue Ampicillin and Gentamicin

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

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)

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)

Mortality diagnosis

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