I.

History
History of Present Illness Four days prior to admission, patient experienced productive cough and colds.

His mother gave him medications. Then three days prior, patient developed fever (38C). He also vomited 3 times per day. He has poor appetite. According to his mother, hes weak and pale in appearance. A day prior to admission, shortness of breath was observed. He had yellowish nasal discharge and productive cough. Fever was also noted (38.3C). Upon admission, harsh breath sounds were heard during auscultation. Positive cough and colds with yellowish nasal discharge was also observed. The admitting vital signs were: Temperature-39.7 C, Pulse Rate-145 bpm, and Respiratory Rate-52 bpm.

Past Medical History During infancy, he has completed the immunizations. By the year 2012, patient was admitted at Dra. Araceli Memorial Medical Center with the diagnosis of Amoebiasis. According to his mother, it was his first time to be admitted in the hospital. He had not yet undergone any surgical procedures.

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Course in the Ward

Upon admission patient was placed on a regular diet with increased fluid intake, started with D5LR. Fast drip done at 10cc/kg then regulated to 50cc/hr. Laboratories requested were CBC, UA, CXR, oral and IV medications were started including Salbutamol neb. Patient placed on high back rest. On the first hospital day, the patient had febrile episode, cough and colds, vomiting, poor appetite and crackles. Medications and hydration were continued. On the second hospital day, patients RR ranged from 40 -50 with rales on both lung fields. Medications and hydration were continued. On the third hospital day, patient has febrile episodes with rales on both lung fields. Oral clarithromycin was started. The patient was discharged on the fourth hospital day with home medications.