1. General Data RP 2 months/Male Manggahan,QC Catholic

2. Chief complaint “LBM”

3. History of Present Illness 3 days PTA (+) 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

4. 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)

5. ROS No cough, no colds, no difficulty of breathing No cyanosis,no pallor No pruritus, no easy bruising, no rash No lymph node enlargement No doubling of vision No ear discharge No bleeding gums No convulsion

6. Family Medical History (-) DM (-) HPN (-) Asthma (-) PTB (-)Malignancies 43 33 Twin A 2 months Twin B 2 months

7. 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

8. 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

9. Feeding history Bottle fed with Nestogen with dilution of 1:1 and consumes 3 oz every 3 hours

10. Immunization history 1 BCG 1 Hepa B 1 DPT

11. Growth and developement Smiles at 2 months Follows objects past midline vocalizes

12. 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

13. Past medical history No history of previous admissions No history of allergies to foods and medications

14. Physical examination Weak looking CR 130 RR 20 T 37 BP 80/50 Weight 3.5 kg (-3)Length 53 cm (-3) Sunken anterior fontanelle, sunken eyeballs Pink palpebral conjunctiva, anicteric sclera,(-) alar flaring, dry lips, dry mucosa (-)Intercostal and subcostal retractions, symmetrical chest expansion, Clear Breath sounds

15. 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

16. Assessment Acute gastroenteritis with severe dehydration R/O sepsis

17. Course at the ER AP 5/17/14 12:00AM CC: LBM Sunken eyeballs Sunken anterior fontanelle (-) Urine output for 12 hours Hgt 143 For CBC and serum electrolytes 4 hours of hydration Stool Exam Blood CS AGE with severe signs of dehydration R/O sepsis Severely underweight,severely stunted wasted PNSS 10cc/kilo for 1 hour then 30ml/kilo for 1 hour then 70ml/kilo for 5 hours Reassess every 1-2 hours Ampicillin Gentamicin

18. AP 5/17/14 6:30 AM Input : 390cc Output: 60cc UO: 2.9 cc/k/hr for 6 hours Sunken eyeballs Sunken anterior fontanelle CBS Full pulses 90/60 130 36.1 CXR APL post hydration CBC: Hbg: 85 Hct: 0.25 Plt: 670 WBC: 24.9 Seg: 0.60 Lympho: 0.40 Na: 137 K: 3.70 Cl: 115 Ca: 2.25 AGE with severe signs of dehydration R/O sepsis Severely underweight,severe ly stunted wasted D5LR 30ml/k for 1 hour Then D5LR 70ml/k for 6 hours Reassess after 1-2 hours WOF: gurgly chest, desaturation,cyano sis

19. AP 5/17/14 9:00 AM (-) Vomiting Decrease amount of watery stool (+) respiratory distress Asleep Comfortable Sunken anterior fontanelle Non sunken eyeballs (+) blood clots on the tongue and hard palate Slightly dry lips Clear breath sounds PT, PTT ABG Sepsis AGE with severe signs of dehydration Severely underweight,sever ely stunted wasted NPO temporarily Hgt now then q8

20. 5/17/14 10:10AM pH: 7.08 PCO2: 11 PO2: 105 SO2: 95% HCO3: 3.3 Beb: -24.5 PT Pt: 11.5 Ctr: 11.2 %act: 94.3 % INR: 1.03 PTT Pt: 38.7 Ctr: 28.3 Sepsis AGE with severe signs of dehydration Severely underweight,severe ly stunted wasted NaHCO3 drip (0.3) Repeat ABG 1 hr post correction Refer to PIDS Plan to shift Gentamycin to Cefotaxime

21. AP 5/17/14 12:10 PM 02 sat: 90 at 10lpm (+) puffy eyelids (+) SC and IC retractions (+) Blood clots per orem Slightly dry lips Good air entry (-) wheezing Full pulses Warm extremities UO: 228ml in 4 hours (admixed with stools BP 80/50 CR 171 RR 70 ABG 1 hour post correction CXR post intubation For CUTZ For stool culture Respiratory Failure Sepsis t/c DIC AGE with severe signs of dehydration Severely underweight,severe ly stunted wasted Intubate pt size 4 level 11.5 RSI D5LR (2x MTN) NaHCO3 7 meqs (2meqs) Inc. Ampicillin to (200) Refer to RICU

22. AP 5/17/14 1:00 PM RICU notes Intubated on CAB BP: 80/50 CR: 150 (-) tears Slightly sunken anterio fontanelle (+) puffy eyelids Slightly dry lips Moist buccal mucosa (+) blood tinge ET secretions Good skin turgor (+) suprasternal retraction Warm ext. FEP Urinalysis Stool exam Stool CS Blood CS TPAG TACS TAGS BUN Crea ALT AST Respiratory Failure secondary to severe metabolic acidosis secondary to GI losses Dec IVF: D5LR (1.5x MTN) Omeprazole (1)

23. AP 5/17/14 2:40 PM PIDS notes Active Puffy eyelids Soft abdomen AGE with severe dehydration Facilitate blood CS Continue Ampicillin and Gentamicin

24. AP 5/17/14 3:05 PM RICU notes BP: 80/50 CR: 130 RR: CAB 02 Sat: 98 Open anterior fontanelle Slightly puffy eyelids Pink conjuctiva Anicteric sclera (+) Bleeding ET tube (+) subcostal retractions Harsh breath sounds AP, tachycardic (-) murmur Globular abdomen,(-) organomegaly Full and equal pulses Warm extremities CRT < 2 secs For PBS Retic count Coombs test Respiratory Failure secondary to severe metabolic acidosis secondary to AGE Sepsis Admit to RICU Hook to MV Continue present medications IVF: D5LR (1.5x MTN) Prepare PRBC 1 unit divided into 3 aliqs for transfusion

25. AP 5/17/14 4:00 PM BP 0 CR 130 Poor pulses (+) Bleeding ET tube 4:03 Pm BP Unappreciated Poor pulses Pupils sluggishly reactive to light 4:06 PM BP unappreciated Poor pulses Pupils sluggishly reactive to light DIC Septic shock Respiratory Failure AGE with severe signs of dehydration Severely underweight,severe ly stunted wasted PNSS 20cc/kilo Dopamine (10mckm) Give another 20cc/kilo Start dobutamine (10mc/k/m)

26. AP 5/17/14 4:10 BP 0 CR 0 Pupils non reactive Pulses unappreciated 4:20 PM BP 0 CR 0 DIC Septic shock Respiratory Failure AGE with severe signs of dehydration Severely underweight,severe ly stunted wasted Start CPR Voluven 10cc/kilo Epinephrine (0.1) Prenounced dead Epinephrine (5doses)

27. Mortality diagnosis DIC Septic shock Respiratory Failure AGE with severe signs of dehydration Severely underweight,severely stunted wasted