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