MINDANAO STATE UNIVERSITY

COLLEGE OF MEDICINE
Department of Pediatrics

GRAND CASE PROTOCOL

GROUP 2, CLASS 2018

Members:
AMBA, Arjay (Case Presenter)
BACULIO, Lindy
BALIQUIG, Arni Rose
DANGEL, Mel
JARABA, Josephine Sande
MACAUROG, Samsia
MAGADAN, Axl Rose
MAMA, Saimah Lynn
OLIVEROS, Drew Harlan
RAZO, Dan Arjeanold
Identifying Data: P.H.M. 5-year old, Male, Filipino, Islam and a resident of Upper Sagaan, Labangan,
Zamboanga Del Sur. He was admitted for the first time at Adventist Medical Center Iligan
as a referral from Pagadian City Medical Center last July 8, 2017 around 2:00 PM.

Informant and Percent Reliability: Patients Mother, 90%

Chief Complaint: Fever

History of Present Illness:

Present condition started 2 weeks prior to admission, as an onset of fever, Tmax undocumented,
intermittent, and associated only with generalized abdominal pain, no bowel movement and occasional non-
productive cough. No medications were taken but sought consult with a private physician and advised for
admission at Pagadian City Medical Center. Patient was then treated as a case of Urinary Tract Infection given with
unrecalled antibiotics. After 3 days of confinement, patient was discharged and advised for follow-up check-up after
a week. Then eight ( hours after discharge, there was recurrence of fever, Tmax undocumented, and parents self-
medicated with Paracetamol syrup (13 mkd) every 4 hours and provided temporary relief. Fever became
intermittent but patients parents tolerated the condition.
A week prior to admission, patient came back for follow-up check-up with still the persistence of fever,
abdominal pain and occasional non-productive cough. The parents were advised for readmission. Further testing
was done and revealed low hematocrit, hemoglobin, and red blood cell levels, leukocytosis, lymphocytopenia,
thrombocytosis and pleural effusion on right lung field. Patient was admitted for three (3) days with the following
medications: Paracetamol IV (10.6 mkd), Ceftriaxone (100 mkD), Gentamycin (2.1 mkD), Meropenem (23.9 mkD),
Salbutamol for nebulization and Acetylcysteine. The attending physician also advised that the patient would be
subjected for thoracentesis, however both parents refused and opted to be referred to Adventist Medical Center
Iligan for further evaluation and management, thus subsequently admitted.

Past Medical History:

Patient was hospitalized last 2016 due to Urinary Tract Infection with unrecalled medications. He had no
history of undergoing any surgical procedure. Patient had a known history of mumps 2 years ago but no other
known history of illnesses like dengue, typhoid fever, asthma, pneumonia, chicken pox, measles, and ear infection.
Patient had no current maintenance medications for any illness. No known history of allergies to food and
medications.

Family History:
The patient has positive family history both on the maternal and paternal side for Hypertension and
Diabetes Mellitus. No known family history of asthma, epilepsy, malignancies, thyroid problem, cardiac disease, and
congenital anomalies.

Birth History:
Patients mother current OB score is G2P2 (2002) with the patient as her first-born child. While being
pregnant with the patient, she had regular prenatal checkups starting 5 months AOG at their local Health Center
and had no manifestations of any maternal illness or complications like infections, bleeding, preeclampsia and
eclampsia. She had been taking vitamin supplements like ferrous sulfate and calcium but had no tetanus toxoid
immunizations.
Patient was delivered via NSD, term, and cephalic presentation, at home assisted by a hilot on August 8,
2011. Birth weight unrecalled. No known complications after birth but no Newborn Screening was done.

Nutritional History:
Patient was not exclusively breastfed after birth but instead started with milk formula. Complementary
feeding was started at 6th months with Cerelac and boiled rice. Patient had good appetite prior to onset of illness
with diet predominantly of rice and fish and less on vegetables. Patients mother had been giving multivitamin
supplements like Tiki Tiki and Ceelin.

Developmental Milestones:
The patient regards face at 1 month of age, smiles at 2 months, able to crawl at 7months, able to stand
alone at 9 months, and able to walk alone at 13 months. Patient was toilet trained at about 2 years old.

Immunization status:
 Patient had 1 dose of BCG, 1 dose of Hep B, 3 doses of DPT and OPV each, and 1 dose of Measles
vaccine given at the health center.
Personal/Social History:
Patient is the eldest child of a 29 year old mother who is a housewife and a 29 year old father working as a
policeman. The patient has only 1 sibling: a 4-year old, female and with no current medical illness. They are
presently residing in Labangan, Zamboanga Del Sur with 4 members in the household. Patient is currently in the
preschool level at a public school in their place. The familys drinking water source is commercially available
mineral water. Only the father is the known cigarette smoker in the family. There are no current individuals related
to the patient who have been diagnosed or undergoing medications for Pulmonary Tuberculosis.

Review of Systems:
General (+) for weakness, weight loss and fever
Skin (-) for itchiness, rashes, and discolorations
HEENT
Head: (-) for headache, masses and scars
Eyes: (-) for redness and irritation
Ears: (-) for pain, discharges, and hearing loss
Nose & Sinuses: (-) for colds and discharges
Mouth &Throat: (-) for sore throat, oral lesions and dysphagia
Respiratory: (+) for cough; (-) for difficulty of breathing, shortness of breath, hemoptysis
Cardiovascular: (-) for cyanosis
Gastrointestinal: (+) for abdominal pain; (-) for LBM, constipation, and bloody stools
Genito-Urinary: (-) for hematuria and dysuria
Neuromuscular: (-) for seizures, loss of consciousness, joint or muscle pain
Hematologic: (-) for bleeding, easy bruising, and epistaxis
Endocrinologic: (-) for heat/cold intolerance
PHYSICAL EXAMINATION

GENERAL SURVEY:
Patient is awake, ambulatory, apparently weak, thin, poorly nourished, well developed, coherent, afebrile,
not in respiratory distress with the following vital signs:
Remarks
Temperature 36.80C, axillary Afebrile
Slightly Tachycardic
Heart Rate 112 bpm
(Normal: 65-110 bpm)
Tachypneic
Respiratory Rate 32 cpm
(Normal:20-25 cpm)
Normotensive
Blood Pressure 90/60
(Normal: 90-110/60-75)
O2 saturation 97% Normal
Normal
Weight 18.8 kg
(Ideal Weight: 18kg)
Normal
Height 110 cm
(Ideal Height: 105 cm)
Normal
BMI 15.5
(Between Z score 1 to -1)
SKIN: No jaundice, no cyanosis, no rashes or other lesions, warm to touch, fair turgor.

HEENT:
Head: Normocephalic, no lesions and scar, no masses
Eyes: Anicteric sclerae, pale palpebral conjunctivae, pupils isocoric, no redness and discharges
Ears: No deformities and discharges
Nose and Sinuses: Nasal septum at midline, no alar flaring, no discharges, sinus areas non-tender
Mouth and Throat: Pale and dry lips and oral mucosa, no oral lesions, non-erythematous oropharyngeal
areas, tonsils not enlarged
NECK: Supple, trachea at midline, no neck vein engorgement, no jugular vein distention, no
lymphadenopathies, no masses

CHEST & LUNGS:

Inspection: symmetrical chest expansion, no retractions
Palpation: no masses, decreased tactile fremitus on R lung field
Percussion: dull on R lung field
Auscultation: decreased to absent breath sounds on R lung field, no wheezing, bronchovesicular
breath sounds on L lung field

HEART:
Inspection: PMI is at 5th ICS, LMCL
Palpation: no heaves or thrills
Percussion: cardiac area of dullness not enlarged
Auscultation: normal rate, regular rhythm, no murmurs

ABDOMEN:
Inspection: flat, no scars, no lesions
Auscultation: normoactive bowel sounds
Percussion: tympanitic all over
Palpation: soft, (+) tenderness on all quadrants, no organomegaly

BACK: (-) for costovertebral angle tenderness and kidney punch test

GENITALIA: grossly male

ANUS: Patent

EXTREMITIES: equally palpable radial and dorsalis pedis pulses, CRT <2 seconds, no edema

NEUROLOGIC EXAMINATION
Cerebral function: patient is conscious, coherent, oriented to time, place and persons, with GCS of 15/15
(Eye=4, Verbal=5, Motor= 6)
Cranial nerves: CN I Not Assessed
CN II Both pupils reactive to light
CN III, IV, VI Intact extraocular movements
CN V Intact corneal reflex, jaw movements, facial sensation
CN VII Symmetrical facial features
CN VIII Hearing Intact
CN IX and X Intact gag reflex
CN XI Able to shrug shoulder
CN XII Tongue at midline

Motor function: Normal tone in all extremities, no muscle fasciculation noted, muscle strength of
5/5 in all extremities
Sensory function: Reactive to pain stimulus, detect light touch
Reflexes:
Deep tendon reflexes: Biceps = +2, right; +2 left.
Knee jerk = +2, right; +2 left.
Ankle = +2, right; +2 left
(-) Babinski Reflex
Meningeal signs: (-) nuchal rigidity, (-) kernigs sign, (-) brudzinkis sign.

IMPRESSION

Pediatric Community Acquired Pneumonia with Pleural Effusion

 To consider Pulmonary Tuberculosis
Anemia Secondary to Poor Nutrition

LABORATORY RESULTS

*PAGADIAN CITY MEDICAL CENTER LAB RESULTS

JULY 5, 2017

COMPLETE BLOOD COUNT

RESULT NORMAL VALUES REMARKS
Hemoglobin 9.40 12-16 g/dL Decreased
Hematocrit 29.50 37-50% Decreased
RBC 3.47 4-6 x 106/mm3 Decreased URINAL
MCV 85 80-100 um3 Normal YSIS
MCH 27 RESULT
26-34 pg NORMALVALUES
Normal REMARKS
MCHC
Color 31.8 Yellow 31-35 g/dL Yellow toNormal
amber Normal
WBC
Character 17.6 Cloudy 5-10 x 103/mm3Clear to Increased
slightly hazy Normal
Diff
pH Count 6.0 4.6-8.0 Normal
Neutrophil
Glucose 73 Negative50-70% NegativeSlightly increased
Normal
Lymphocyte
Protein 15.6 Negative25-50% NegativeDecreased Normal
Monocyte
SG 9 1.015 2-10% Normal
1.005-1.030 Normal
Eosinophil
Nitrite 1.7 Negative0-5% NegativeNormal Normal
Basophil
Blood 0.7 Negative0-2% NegativeNormal Normal
Platelet
Bilirubin 1221 Negative150-450x103/mm 3
Negative Increased Normal
Urobilinogen Negative Negative Normal
Ketones Negative Negative Normal
Leukocytes Negative Negative Normal
Pus cells 3-5/hpf 4-5/hpf Normal
RBC 0-1/hpf 0-2/hpf Normal
Epith Cells Rare Absent to few Normal
Bacteria Rare Negative Normal
Crystals Negative Absent to few Normal
Casts Negative Negative Normal

TUBEX TYPHOID TEST

RESULT REMARKS
Score: 0 Interpretation: NEGATIVE

JULY 5, 2017

CHEST X-RAY PAL VIEW

> A homogenous opacity obscures the R mid to lower lung field and ipsilateral hemidiaphraghm
and costophrenic angle reaching up to the level of the 2nd anterior rib
> Heart not enlarged
> Trachea at midline
> Left hemidiaphragm and costophrenic angle are intact
 > Chest wall structures are unremarkable

IMPRESSION: MODERATE PLEURAL EFFUSION, RIGHT

CANNOT TOTALLY EXCLUDE INTERCURRENT CONSOLIDATION
PLEASE CORRELATE CLINICALLY WITH OTHER MODALITIES

JULY 7, 2017

COMPLETE BLOOD COUNT

RESULT NORMAL VALUES REMARKS
Hemoglobin 8.80 12-16 g/dL Decreased
Hematocrit 27.60 37-50% Decreased
RBC 3.28 4-6 x 106/mm3 Decreased
MCV 84 80-100 um3 Normal
MCH 27 26-34 pg Normal
MCHC 32 31-35 g/dL Normal
WBC 15.80 5-10 x 103/mm3 Increased
Diff Count
Neutrophil 73.70 50-70% Slightly INCREASED
Lymphocyte 17.20 25-50% Decreased
Monocyte 6.40 2-10% Normal
Eosinophil 2.00 0-5% Normal
Basophil 0.70 0-2% Normal
Platelet 1155 150-450x103/mm3 Increased

CHEST ULTRASOUND
> Real time sonographic evaluation of the chest reveal moderate amount of complicated pleural
fluid on the R exhibiting suspended debris, loculations, and septations measuring at least 446 cc.
No pleural based mass lesions seen.

> Left lung is well aerated. No measurable amount of fluid is noted in the left hemithorax.

IMPRESSION: MODERATE AMOUNT OF COMPLICATED PLEURAL FLUID, RIGHT

*AMC LAB RESULTS

JULY 8, 2017
BLOOD TYPING
BLOOD TYPE Rh
O (+) Positive

COMPLETE BLOOD COUNT

 RESULT NORMAL VALUES REMARKS
Hemoglobin 90 130-160 g/L Decreased
Hematocrit 0.29 0.40-0.54 Decreased
RBC 3.45 5-10 x109/L Decreased
WBC 11.24 5-10x109/L Increased
Diff Count
Neutrophil 0.76 0.50-0.65 Increased
Lymphocyte 0.19 0.25-0.35 Decreased
Monocyte 0.03 0.03-0.07 Normal
Eosinophil 0.02 0.01-0.03 Normal
Basophil 0 0-0.01 Normal
Platelet 800 140-450x 103 Increased

URINALYSIS
RESULT NORMAL VALUES REMARKS
Color Yellow Yellow to amber Normal
Transparency Clear Clear to slightly hazy Normal
SG 1.005 1.005-1.030 Normal
pH Reaction 6.0 4.6-8.0 Normal
Protein Negative Negative Normal
Sugar Negative Negative Normal
WBC/hpf 1-2/hpf 4-5/hpf Normal
RBC/hpf 1-2/hpf 0-2/hpf Normal
Epith Cells Occasional Absent to few Normal
Crystals Negative Negative Normal
Casts 0 Absent to few Normal
Mucus Occasional Negative Normal
Bacteria Occasional NEgative Normal

SERUM ANALYSIS
RESULT NORMAL VALUE REMARKS
Serum K 4.84 mmol/L 3.3-5.3 mmol/L Normal
Serum Na 114.5 mmol/L 134-143 mmol/L Decreased

JULY 8, 2017

CHEST X-RAY APL VIEW

> Streaks of densities seen in both lungs
> Homogeneous pleural based convex density seen at the periphery of the Right Thorax
> The right costophrenic sulcus obliterated, with partially obscured right hemidiaphragm.
> The heart and thymus are normal in size and orientation.
> The bony thorax is normal.

IMPRESSION: BILATERAL PNEUMONIA

RIGHT PLEURAL EFFUSION WITH SUGGESTIVE LOCULATION PYOTHORAX IS
CONSIDERED. SUGGEST SONOGRAPHIC CORRELATION

JULY 9, 2017
SERUM CREATININE
RESULT NORMAL VALUE REMARKS
35.3 umol/L 2.65-52.2 umol/L Normal

STOOL EXAM
 RESULT
Color Yellow
Character Loose
Occult Blood N/A
Pus Cells 0
Mucus Negative
RBC/hpf 0
Amoebas Negative
Flagellates Negative
Ascaris Lumbricoides Occasional

JULY 11, 2017

CHEST CT SCAN WITH CONTRAST
> There is consolidation/subsegmental atelectasis of the R lover lobewith heterogeneous enhancement on
IV contrast study. Some vessels are seen coursing within the consolidated segment. Air bronchogram
noted. Hazy densities seen in the rest of the lung fields. No delineable mass lesions noted.
> Trachea, carina, main bronchi and rest of the bronchi are not unusual.
> The heart is not enlarged. Pericardium is not thickened. No pericardial effusion seen.
> Moderate free and loculated pleural fluid in the right.
> The visualized soft tissue and osseous structures appear within normal. No bone infiltration.
> The included liver, gallbladder, spleen, adrenals and visualized upper pole kidneys are not unusual. No
other significant findings.

IMPRESSION: BILATERAL PNEUMONIA WITH CONSOLIDATION/SUBSEGMENTAL ATELECTASIS IN

THE RIGHT LOWER LOBE AS DESCRIBED.
KOCHS ETIOLOGY NOT RULED OUT.
CLINICAL/LABORATORY CORRELATION.
MODERATE PLEURAL FLUID IN THE RIGHT.
ULTRASOUND CORRELATION.

JULY 13, 2017

PLEURAL FLUID ANALYSIS

RESULT
Character Slightly Bloody
Color Orange
Volume 2cc
RBC 300 cells/uL
WBC 100 cells/uL
% Segmenters 100%
WBC = Occasional
RBC = 4+
Gram Stain
No Microorganism Seen

AFB (Acid Fast Stain) 0

CHEST X-RAY AP (FOLLOW-UP S/P RIGHT THORACENTESIS)

> Showed streaks of densities seen in both lungs

> Remarkable regression of the R lung opacity with minimal residual ribbon-like density at the periphery.
> The right costophrenic sulcus was obliterated, with partially obscured R hemidiaphragm
> The heart and thymus are normal in size and orientation.
> The bony thorax is normal.
IMPRESSION: BILATERAL PNEUMONIA.
REMARKABLE REGRESSION OF THE RIGHT PYOTHORAX WITH MINIMAL
RESIDUAL VOLUME AND PLEURAL THICKENING.
NEGATIVE FOR PNEUMOTHORAX.
ON ADMISSION

JULY 8, 2017

2:00 PM
Patient was admitted to room of choice and diet for age was instructed. Vital signs monitoring every 4 hours
and urine input/output recording every shift. Venoclysis started with D5 0.3 NaCl 500cc at 60 cc/hr
(3.2cc/kg/hr). Laboratory studies were ordered: complete blood count with platelet count, blood typing,
serum Na+ and K+, chest x-ray APL view, urinalysis, and stool exam.

The following medications were ordered by resident on duty and eventually started:
Paracetamol syrup 10.6 mkd q 4 hrs for fever
Salbutamol 1 neb + 2cc Plain NSS, 1 nebule q 6 hrs

3:40 PM
The attending physician (AP) ordered for Mantoux Test or Purified Protein Derivative Test while Pedia Post-
Grad Intern performed the test on Left arm and interpretation was due on July 11, 2017 at 3:45 PM.

6:40 PM
Lab results were received for CBC, blood typing, urinalysis, serum K and Na, and chest X-Ray.

AP ordered for surgical co-management with a pedia surgeon for possible ultrasound-guided thoracentesis.
The following medications were also ordered:
Ceftriaxone 95.7 mkD IV Drip q 24 hrs ANST
Amikacin 15mkD IVTT q 12 hrs ANST
Ranitidine 1 mkD IV q 8 hrs.
IV fluids to follow was D5NM 1 L (3.2cc/kg/hr).

10:45 PM
The pedia surgeon visited the patient for assessment and then ordered for preparation for Ultrasound
guided Right Thoracentesis for the next day.

11:40 PM
The AP ordered for the following to be included for pleural fluid analysis after thoracentesis:
1 Total cell count/differentiated count
2 Culture and sensitivity, gram stain, Kochs AFB Stain
3 Pleural fluid cytology
4 Glucose, LDH, total proteins
COURSE IN THE WARD

JULY 9, 2017 Hospital Day 1

Patient still had fever, body weakness, occasional cough but no recurrence of abdominal pain. No
tachypnea, dyspnea, and other associated symptoms. Patients vital signs were within normal limits except
for an increase in temperature and tachycardia. Patient still had pale conjunctivae, lips and oral mucosa.
Chest and lung findings still reveal a Right lung field with decreased tactile fremitus, dull and decreased
breath sounds. Abdomen still flat, with normoactive bowel sounds, soft and no tenderness on all quadrants
upon palpation.

The following medications still continued: Ranitidine, Ceftriaxone, Amikacin and Salbutamol neb + PNSS.

Patient undergone ultrasound-guided R thoracentesis around 2:00 pm but no pleural fluid aspirated (dry
tap). Paracetamol thru IV 11 mkd was given then last dose given after 4 hrs.

Chest CT Scan with contrast at Mercy Community Hospital was ordered by AP.

The following medications were ordered:

Isoniazid + Pyridoxine HCL (INH) 11 mkD once daily before breakfast
Rifampicin 15 mkD once daily before breakfast
Pyrazinamide (PZA) 12 mkD once daily after dinner
Prednisolone 1.06 mkD PO PC dinner

IV fluid to follow still D5NM 1 L at same rate.

Around 10:40 PM, patient complained of hypogastric pain, and vomiting, 1 episode of previously ingested
food. The following medications were then ordered and given:
Buscopan amp (0.5 mkd) q 6h PRN for pain

Erceflora 1 vial BID

JULY 10, 2017 Hospital Day 2

Patient was afebrile, apparently weak with occasional cough. No complains of any pain and vomiting. No
tachypnea, dyspnea, and other associated symptoms. Patients vital signs were within normal limits except
for tachycardia. Physical exam showed pale conjunctivae, lips and oral mucosa and right lung field with
decreased tactile fremitus, dull and decreased breath sounds.

The following medications still continued: Ranitidine, Ceftriaxone, Amikacin, INH, Rifampicin, PZA,
Buscopan, Erceflora, and Salbutamol neb + PNSS.

Stool exam result was relayed to AP.

The following medications were ordered and started eventually:

Prednisolone (20mg/5ml) 5ml OD PC Breakfast
Multivitamins 5ml once daily
Mebendazole 500mg tab (27mkD) once only

IV fluid to follow still D5NM 2 L at same rate.

JULY 11, 2017 Hospital Day 3

 Patient was alert, afebrile, with occasional cough. No complains of pain and vomiting. No tachypnea,
dyspnea, and other associated symptoms. Patients vital signs were within normal limits except for
tachycardia. Physical exam still showed pale conjunctivae, lips and oral mucosa, and right lung field with
decreased tactile fremitus, dull and decreased breath sounds.

The following medications still continued: Ranitidine, Ceftriaxone, Amikacin, INH, Rifampicin, PZA,
Prednisone, Buscopan, Erceflora, Salbutamol neb + PNSS, and Multivitamins.
Follow-up for CT Scan Result from Mercy Community Hospital was ordered.

Mantoux Test results showed an induration < 5mm on the Left arm.

JULY 12, 2017 Hospital Day 4

Patient was alert, afebrile, with good appetite and still have occasional cough. No complains of pain and
vomiting. No tachypnea, dyspnea, and other associated symptoms. Patients vital signs were within normal
limits except for tachycardia. Physical exam still showed slightly pale conjunctivae, lips and oral mucosa,
and right lung field with decreased tactile fremitus, dull and decreased breath sounds.

The following medications still continued: Ranitidine, Ceftriaxone, Amikacin, INH, Rifampicin, PZA,
Prednisolone, Erceflora, Salbutamol neb + PNSS, and Multivitamins.

JULY 13, 2017 Hospital Day 5

Patient was alert, afebrile, with occasional cough. No complains of pain and vomiting. No tachypnea,
dyspnea, and other associated symptoms. Patients vital signs were within normal limits. Physical exam still
showed slightly pale conjunctivae, lips and oral mucosa and right lung field with decreased tactile fremitus,
dull and decreased breath sounds.

The following medications still continued: Ranitidine, Ceftriaxone, Amikacin, INH, Rifampicin, PZA,
Prednisolone, Erceflora, and Multivitamins.

Fluimucil 1ml was ordered to be added in Salbutamol 1 neb q 6h with no NSS incorporation. Securing of
incentive spirometry was also ordered. IV fluid to follow still D5NM 2 L at same previous rate.

CT Scan images were seen by AP and Pedia surgeon.

Ultrasound-guided thoracentesis scheduled at 8:00 PM by Pedia Surgeon. Patient was ordered NPO 5 hrs
prior to surgery and given Metoclopramide 7mg IV prior wheeling to OR.

After thoracentesis, pleural fluid effusion aspirated was serosanguinous approximately 10cc and then
subjected to pleural fluid studies.

Patients diet as tolerated once awake, then Paracetamol IV 11mkd given then for the next 6 hours for 2
doses only. Chest X-ray AP view was ordered after post-thoracentesis.

At 9:20 PM AP ordered that Prednisolone (20/5) 13 mkD be given BID after breakfast and dinner.

JULY 14, 2017 Hospital Day 6

Patient was alert, afebrile, with occasional cough. No complains of pain. No tachypnea, dyspnea, and other
associated symptoms. Patients vital signs were within normal limits. Physical exam still showed slightly
pale conjunctivae, and right lung field with slightly decreased tactile fremitus, dull and decreased breath
sounds.
 The following medications still continued: Ranitidine, Ceftriaxone & Paracetamol IV (both D/C afterwards),
Erceflora (to consume stock then D/C), Amikacin, INH, Rifampicin, PZA, Salbutamol neb + Fluimucil,
Multivitamins, and Prednisolone.

Remaining IV Fluids consumed and then shifted to IV lock.

The results of Pleural Fluid Analysis and follow-up Chest X-Ray were relayed.

The following medications were ordered and started eventually:

Cloxacillin (250/5) 80mkD TID after on full stomach
GI protect 1 sachet once daily

JULY 15, 2017 Hospital Day 7

Patient was alert, afebrile, with occasional cough. No complains of pain with no tachypnea, dyspnea, and
other associated symptoms. Patients vital signs were within normal limits. Physical exam still showed
slightly pale conjunctivae, and right lung field with slightly decreased tactile fremitus, dull and decreased
breath sounds.

The following medications still continued: Ranitidine (consume stock then D/C), Amikacin, INH, Rifampicin,
PZA, Prednisolone, Salbutamol neb + Fluimucil, Multivitamins, GI Protect and Cloxacillin.

Around 11:25 AM, Cloxacillin was put on hold then started with Clindamycin (75/5) 32 mkD QID on full
stomach.

At 9:06 PM, Clindamycin D/C and shifted to Cloxacillin.

Hospital Day 8
JULY 16, 2017
Patient was alert, afebrile, with occasional cough. No complains of pain with no tachypnea, dyspnea, and
other associated symptoms. Patients vital signs were within normal limits. Physical exam still showed
slightly pale conjunctivae, and right lung field with slightly decreased tactile fremitus, dull and decreased
breath sounds.

The following medications still continued: INH, Rifampicin, PZA, Prednisolone, Salbutamol neb + Fluimucil,
Multivitamins, GI Protect and Cloxacillin.

Pedia surgeon advised for no further surgical intervention for now.

AP ordered for patients discharged with the following take-home medications and instructions:
1. Cloxacillin (250/5) 10 ml (80mkD) TID for 1 month taken on full
stomach
2. Multivitamins 5ml OD
3. GI protect 1 sachet once daily for 1 month
4. Prednisolone (20/5) 2.5 ml (1.1mkD) BID for 36 days
5. Medz Kit:
INH 200mg/5ml 5ml once daily before breakfast x 6mos
Rifampicin 200 mg.5ml 7ml OD before breakfast x 6 mos
PZA 500mg/5ml 5.5 ml once daily after dinner x 3 mos
Follow-up after 1 month with repeat Chest X-Ray PAL view

Hospital Day 9
JULY 17, 2017
 Patient was discharged.

FINAL DIAGNOSIS

PCAP with Pleural Effusion

Staphylococcus Pneumonia with Primary Complex
Intestinal Parasitism (Ascariasis)