RT, 5/M

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

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

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

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

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

PHYSICAL EXAMINATION -ER

- received unarousable - BP 80/40 HR 110 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

PHYSICAL EXAMINATION -ER

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

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

COURSE AT THE ER

Infectious/NeurologicP: 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

Infectious/NeurologicP: 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

COURSE IN THE WARDS

INFECTIOUS/NEUROLOGIC S/O : still with hypotensive episodes (70/40)

: (+) melena (+) coffee ground material/NGT

12LECG: (-) low voltage QRS

Infectious/Neurologic

8/8 8/8 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

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

Pt 79.4

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

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

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

PCOD: septic shock