1. RT, 5/M

2. RCT, 5/M from Paranaque admitted for the first time for diarrhea and vomiting

3. HISTORY OF PRESENT ILLNESS
2 days PTA: (+) increased sleeping time
(+) lethargic
1 day PTAloose watery stool, non-
mucoid, non-bloody
>5x/day ½ cup/episode
non-projectile vomiting
>5x/day
 high grade fever

4. HISTORY OF PRESENT ILLNESS
1 day PTA brought to local hospital
 persistence of symptoms
 3 episodes GTC seizures
5 mins duration,
1 min interval,
no regain in consciousness
Transferred to PGH

5. REVIEW OF SYSTEMS (+) cough/colds x 1 month duration (-) DOB
(-) chest pain
(-) ab pain
(-) urinary changes
(-) polyuria
(-) polyphagia
(-) polydipsia
(-) rashes
(-) behavioral changes

6. PMHx: (+) typhoid fever – 2006
FMHx: (+) PTB – grandfather tx for 6 mos 2007
(+) liver Ca – grandmother
ImmHx: unknown to informant
BMHx: Born FT to a ? Yo G1 at a local hospital
Devt Hx: at par with age
P/SHx: Pt is the eldest of 2 siblings. Parents
separated when he was 2 yo
Lives with maternal grandparents
Drinking water is from the faucet

7. PHYSICAL EXAMINATION -ER
- received unarousable
- BP 80/40 HR RR30 febrile
- anicteric sclerae, pink conj, (+) sunken eyeballs
- ECE, (+) course crackles, (-) rales/wheezes
-AP, distinct heart sounds, NRRR, murmur
- fair pulses, pink nailbeds, (-) cyanosis/edema

8. PHYSICAL EXAMINATION -ER
(+) spastic extremities with opisthotonos
pupils 3-4 mm SRTL, (-) facial asymmtetry,
(+) drooling
withdraws to pain
DTR +++ on all extremities, (+) babinski

9. Initial Working Impression
AGE with severe signs of Dehydration Acute symptomatic seizure prob secondary to 1) metabolic 2) CNS infection (TB, bacterial) Community Acquired Pneumonia r/o sepsis

10. COURSE AT THE ER

11. Infectious/Neurologic
P: Dx: CBC
BUN, Crea, Na, K, Cl, Ca, Mg, RBS, AST, ALT, Ck-MB
blood CS, ETA GS/CS
PT/PTT
12LECG
U/A
CXR APL
Cranial CT scan
Lumbar tap, HSV, Jap B titers
Tx: Pen G (200,000)
Chloramphenicol (100)
t/s Ceftriaxone  Acyclovir
Pb (20) as LD then (5) as MD

12. Infectious/Neurologic
P: intubated ET5 L14
given total 80cc/kg pNSS
Dopamine (10), Dobutamine (10) started
given 5cc/kg D10W
given O2 support at 5-6LPM
IVF: D50.9NaCl
660 cc (30cc/kg x 30 mins) then,
195cc/hr (70cc/kg x 5 hrs)
 FM: 58cc/hr

13. COURSE IN THE WARDS

14. INFECTIOUS/NEUROLOGIC
S/O : still with hypotensive episodes (70/40) : (+) melena (+) coffee ground material/NGT 12LECG: (-) low voltage QRS

15. Infectious/Neurologic
8/8
8/9 pH
7.281
7.303
7.517
7.174
pCO2
12.8
13.3
8.10
20.6
pO2
163
174
173
378
HCO3
6.10
6.70
6.60
7.60
Beb
-17
-16.8
-12.5
-17.9
O2 sats
99.3
99.5
99.7
99.9

16. Infectious/Neurologic
8/8
Alb 22 Ca
2.05 Na
137 K
5.3 Cl
100
PT – Ctrl
12.9 Pt
24.8
Act
0.34
INR
2.36
PTT Ctrl
35.6
79.4

17. Infectious/Neurologic
A: AGE with severe signs of Dehydration Acute symptomatic seizure prob sec to 1) Suppurative Meningitis 2) Salmonella/Shigella Meningitis 3) Viral encephalitis r/o sepsis CAP

18. Infectious/Neurologic
P:Tx: Vit. K (1) Omeprazole (0.8) Dopamine (20) , Dobutamine (20) Epinephrine (1) Ceftriaxone (100)  Pen G + Chloramphenicol IVF: D50.9NaCl (FM+100%) For BT of FFP  DNR directive

19. Referred for HR = O DNR directive noted Pronounced 5:15 PM Post mortem care rendered

20. PCOD: septic shock