Admission

Diagnosis:
Age w/ moderate
dehydration, Global
Developmental
Delay, P.CAP c
Epilepsy, Pocali;
Prob structural
Case Handled: March 03, 2020
By: Felix, Irish Eunice A
Sec: BSN – 2A
Demographic Data

This is a case of a 1 year old male baby (CAT) who was diagnosed PCAP, born on 03 /
01/2019 Filipino, Roman Catholic, currently residing in Pasay City, admitted for
Vomitting in Pasay City General Hospital on March 01, 2020.

Chief Complaint

Vomitting

History of Present Illness

4 days prior to admission, the patient experiences vomiting of previously ingested milk
and food, associated with fever (39.9 C), with cough, loose bowel movement (Semi-
formed, yellowish, non billous, non bloody) prompted consult to QMMC, the patient was
given Pedialyte with no relief, advised to transfer to PCGH, lab tests were done. CBC
results: Hgb: 127, Hct: 0.39, WBC: 16.5, Neutrophils: 0.72, Lymphocytes: 0.16,
Monocytes: 0.12, Platelet count: 377. Serum chemistry Results Na: 136, K:4.1, Cl: 101.
Ca: 2.34, Mg: 0.93, BUN: 3.9, Creantinine: 23. Medications given: Oxcarbazepine, Zinc
Sulfate, Oral rehydration solution, and Rececadotril and afford mild relief of symptoms.

1 day prior to admission, still with vomiting and increased frequency of loose bowel
movement (10 episodes, yellowish watery stools). No medications taken, no consult
done.

Few hours prior to admission, still with the persistence of symptoms, hence consultation
in our institution and subsequently admitted.

Past Medical History

(-) Previous hospitalization

(-) Allergies
(-) TB exposure

Family History

(-) Hypertension (-) Asthma

(-) Malignancies (-) Diabetes Mellitus
(-) Exposure to TB

Birth and Maternal History

Born preterm to a 23 year-old G1P1 mother via SVD by a doctor at Catarman provincial
hospital. No pre-natal complications. (+) UTI during six months of pregnancy. No intake
of drugs or alcohol during pregnancy. No exposure to radiation and chemicals during
pregnancy, with regular prenatal check up.
Nutritional History

Patient was breastfed and also bottle fed. Patient has no known allergy to food and
medications.

Personal / Social History

Patient is the first child of 23 year old mother, and a 23 year old father.

Immunization History

(+) BCG (+) DPT (+) Hepatitis B Vaccine

(+) OPV (+) Measles (-) MMR

Medications

His medications are Zinc Sulfate, Racecadotril (Hidrasec), Paracetamol, Probiotics OD,
Oxcarbazepine

Patient’s Vital Sign March 03, 2020

7:00 AM

BP/02: 96
RR: 60 (MV)
CR: 155
TEMP: 37.1 C

Case Discussion

This is a case of a 1 year old male baby (CAT) who was diagnosed PCAP, born on 03 /
01/2019 Filipino, Roman Catholic, currently residing in Pasay City, admitted for
Vomitting in Pasay City General Hospital on March 01, 2020.

Pediatric Community Acquired Pneumonia