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AssessmentOrdersAdmissionMay 31, 2015 1:10pmPt. is 2 months old came in due to fever and very irritable, no cough and colds notedBP 78/59 HR 140 RR 46 T-38.7Noted CBC results:Hgb 85, hct26, wbc 39.1, band 5, neutrophil 74, lymphocyte 15, platelet 714, Advised admissionAdmitted under dr. MCbc with pc, hgt, peripheral blood smear,blood culture and sensitivityChest xrayUrinalysisD5IMBB 500ml x 27ml/hr (M+10%)Paracetamol 100mg/ml 0.6ml every 4 hours as needed for temp > 38Ampicillin 150mg/iv every hours for infectionAmikacin 88mg/iv once a day for infectionPulse oximeter check all extremities

May 31, 2015 3:15pmRounds with DR. MPlease add reactive protein to bloodworksHook to pulse oximeter5:30pmGoing Day 1 of illness, last febrile episode 38.5 at 2pm, less irritable, good suck cry and activityT: 37.5, HR 174 RR36, BP 80/50Nonsunken eyeballs,clear breath sound, regular cardiac rhythm, soft abdomen, full pulsesMay go up to room 9th floorLab results already relayedIv insertion at unit pls

6:15pmReceicing notesLast fever noted at 2pmDecreased duration of breastfeeding, stops in between feeds, fair cry compared to night prior,less head movement, no cough and colds,T 37.6 HR 112 RR40 BP 90/60, GCS 15/15Secure IV access and start antibiotics as previously orderedAccurate input and output monitoring and recordInsert finalized xray result to chartWOF poor suck, cry and activity, o2 sat

10:30pm at PICUSudden onset of respiratory distress, with fever and tachycardiaSeen crying, irritable, in respiratory distress , pale, alar flaring, dry mouth and lipsHR 203, RR 60, T 38.6Increase oxygen at 10lpm non rebreather maskIncrease iv fluids t mild hydration : ongoing PNSS at 3ml/hr for 8hoursDifficult arterial sample extraction for EG7, may do needle prick method insteadGive paracetamol now (opiogesic 125mg/suppository suppositoryExternal cooling measure for feverGive another 150 mg ampicillin iv now

11:00pmRounds with Dr BSudden onset of difficulty of breathing/ respiratory distress with fever and tachycardiaSeen awake irritable, in respiratory distress, paleHR 190-200, RR 65-75, spo2 100% at 10lpm non rebreather maskContinue present ivf PNSS at 37ml/hr for 8hours then will reassessPlace on NPOContinue oxygen support at 10lpm non rebreather maskReuest for stat chest CT scan (plain) nowGive another 150mg Ampicillin per iv now then continue ampicillin 300mg/iv every 6 hours diluted with 10ml normal salineContinue amikacin 88mg/iv as one hour infusion every 24hoursParacetamol 125mg per suppository suppository every 4hours as needed for fever 38 and abovePlease reserve 1u PRBC properly typed and crossmatched, Divide 1 u into 3 aliqouts, 70ml each

June 1, 201512:30amChest CT scan initial reading showed consolidation and atelectasis on the left Lucency seen on the left lower lobe may represent abcess formation. CCAM not totally ruled out, contrast studt is advisedFor tracheal aspirate GS and culture and sensitivityStart Clindamycin (dalacin c) 50mg/iv now then every hoursCreatinine reuestedFor follow up chest CT scan with contrast2amLatest VSHR 162, RR 74, spo2 100%No alar flaring, regular cardiac rhythm, no murmur, sabcostal and supraclavicular retractions shallow, good air entry, clear breath sounds Good peripheral progressionCreatinine 0.32mg/dlProceed now with Chest CT scan with Contrast6:50amHR 135-156bpm, BP 10/50, RR 55-65cpm, spo2 100% at 10lpm non rebreather maskUo : 54ml/kg/hr laast 8hoursDecrease iv fluid rate to full maintenance at 25ml/hrDecrease Oxygen support to 6lpm face mask

8:45amRounds with DR. BVS: HR 132bpm, RR 48cpm, spo2 100% at lpm via face maskNo alar flaring, shallow sabcostal retractions, good air entry, clear breath sound, regular cardiac rhythm, abdomen soft, strong pulses.Shift oxygen support to nasal cannula at 3lpmShift iv fluid to D50.45% NaCl 500ml to run for 25ml/hrFor repeat cbcpc, serum Na, K tom une 2, 2015 after 7pm dose of clindamysinFollow up culture resultsReassess this afternoon if breastfeeding can resumed9:15amRounds with Dr. MAfebrile, Decrease O2 support to 3lpm no episodes of tachycardia when asleepFollow up official CT results and attach to chartFollow up blood culture and chart10:05amRunds with Dr RIrritable, good suck, no cyanosis, interrupted feedingO2sat 100% at 3lpm via nasal cannulaMa resume breastfeeding with strict aspiration precautionMaintain head in upright while feedingSuggestions:Continue antibiotics to treat infectionsDecrease oxygen to maintain O2sat >95%Repeat xray after impression is controlled unless there is clinical deterioration

1:35pm2:15pm3:10pmDecrease O2 at 2lpm

Discontinue Hgt MonitoringRefer ABG CVBG extracted yesterdayFor cranial ct ultrasound bedsideJune 2, 20155:00amIVFTF #2 D5 045% NaCl 500ml to run for 20ml/hr8:45amBP 93/56, HR 153 RR 46, T37.3No alar flaring, shallow sabcostal retractions, good air entry, clear breath sound, regular cardiac rhythm, abdomen soft, strong pulsesCarry out 7pm cbc and relay to PROD once available, refer

12noonRounds with dr bMarked clinical improvement, intermittent low grade fever past 24 hours (last fever 4am today)Stable Vital signsMaintain O2 support at 1lpm per nasal cannulaIv fluids D5 half normal saline at 35% of maintenance, 18ml/hrFollow up tracheal aspirate culture identificationRelay repeat cbc and serum electrolytes results as soon as availableContinue antibioticsBreastfeed as tolerated/per demand6:35pmDr b updatedInclude ck enzymes in next bloodworks to check for myocarditis10:40pmHgb 59, hct 0.19Transfuse prbc 60ml at 10ml/hrUse syringe pump for blood transfusionOnce on blood transfusion, please decrease ivf to 8ml/hrOnce ongoing ivf is consumed ivftf D5 0.45 NaCl 500ml +5me KClJune 3, 20157:30amRepeat cbc with platelet at 12noon today

Latest CBC : hgb 110, hct