1. Course in the Ward

2. 1 st Hospital Day Patient presented with respiratory distress and fever. Given oxygen supplementation at 4-5 liters per minute via mask. She was put on NPO and was started on IVF of D5 0.3 NaCl to run at 29 -30 drops/hr. CBC with platelet count and Chest X-ray were requested. CBC showed leukocytosis (WBC18.20) and chest x-ray showed the presence of infiltrates on both lung fields. Patient was given Cefuroxime 250mg/Iv (107 mkd), Paracetamol 100 mg/SIVP for fever and 0.65 % NaCl nasal drops.

3. 1 st Hospital Day Patient was started on Gentamycin 30 mg/SIVP. Patient had showed progression of respiratory distress. ABG was requested and it showed respiratory acidosis with hypoxemia. The patient was intubated, a nasogastric tube inserted and was admitted to the pediatric intensive care unit. She was hooked to a cardiac monitor, pulse oximeter and mechanical ventilator. Chest x-ray after intubation showed progression of the previously noted infiltrates bilaterally and the presence of endotracheal tube at the level of T2-T3. Blood culture and sensitivity were requested. Patient was referred to pediatric pulmonology for further evaluation and management. Cefuroxime was discontinued and patient was started on Vancomycin. Patient was also started on nebulization with Salbutamol.

4. 2 nd Hospital Day Midazolam was given. Nebulization with Salbutamol alternating with salbutamol + Ipratropium was continued followed by chest physiotherapy. Tracheal aspirate grams stain showed absence of microorganisms. Repeat CBC showed low hemoglobin (82 mg/dL) Patient was transfused with 70 mL PRBC. Serum Na, K, SGPT and creatinine were requested and results were normal. Indwelling catheter was inserted.

5. 3 rd Hospital Day Meropenem 300 mg/dose IV infusion every 8 hours (128 mkd). Started feeding with milk formula was started at 30 ml every 3 hours given via nasogastric tube.

6. 6 th Hospital Day Arterial blood gas determination showed metabolic alkalosis. Chest x-ray showed confluence of densities in right upper lobe with slight shifting of minor fissure upwards, alveolar infiltrates are again seen in left upper and right lower lobe, and lung fields are slightly hyperaerated. Endotracheal tube aspirate culture and sensitivity showed presence of Haemophilus haemolyticus. Repeat CBC showed increased in hemoglobin from 82 to 119, and decrease in WBC from 17.8 to 11.1.

7. 7 th Hospital Day Swas given Hydrocortisone 30mg/SIVP every 6 hours (4.2 mkdose). Midazolam was decreased 1mL/hr.

8. 9 th Hospital Day Extubation was done. Salbutamol nebulization was done and she was hooked to O2 per mask at 5 lpm. Serum Na and K were done with normal results.

9. 10 th Hospital Day IV hydrocortisone was shifted to oral 2.5mL BID (Prednisone 10mg/5ml). O2 was also shifted to funnel at 2-3lpm to maintain O2sat >95%.

10. 11 th Hospital Day O2/funnel was discontinued, NGT was removed. Patient was transferred to ward. Medications – Meropenem 300mg/SIV infusion (128mkd) every 8 hours to complete 10 days – Gentamycin 35mg/SIVP (5mkd) everyday until 11/22/10 – Prednisone 10mg/5ml 3.5 ml (1.4mkd) BID after feeding – Zinc 10mg/ml 1ml QD – Salbutamol nebulization 1ml + 1 ml NSS q6h – Zinc oxide cream apply over perianal area after each diaper change.