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Department of Health

EAST AVENUE MEDICALCENTER

East Avenue, Quezon City

DISCHARGE SUMMARY
Name: __PASILAN, DIANA ARDIETA__ Ward: _5 EAST Room No. _5034D
Case No. 01311600-1
Sex ____F_____
Civil Status __S___
Attending Physician: _Dr. Sabangan__
Date Admitted: ____7-17-14______
DATE: 7-26-14

I.

CLINICAL ABSTRACT:
We have our patient, Diana Ardieta Pasilan, 22 year old, female, Filipino, Catholic, residing at Riverside St.
Commonwealth Quezon City who was admitted due to seizure.

II:

LABORATORY EXAMINATION:

7/23/14 ANA (1:10) 0.3 RATIO FEIA


7/23 BUN 8.7 mg/dL, Crea 0.5 mg/dL
7/23 WBC 10.9, Hgb
98, Hct 0.299, N 0.73, L 0.25, M 0.02, PLT 221 7/17 CXR Negative 7/21 ESR 44 mm/hr 7/22 K 3.6 mmol/L
7/18 CT Scan of the Head; No intracranial abnormality, Left sided chronic oto-mastoiditis

III.

COURSE IN THE WARD:

Upon admission (7/17/14), patients vital signs, input and output and neuro vital signs were monitored every hour.
Patients vital signs were stable, patient was drowsy, unable to follow commands. IVF PNSS 1L x 100cc/hr was
started. NGT was inserted. Feeding via NGT 1600kcal divided into 6 equal feedings. IFC was inserted. The following
diagnostics were requested, CT scan with contrast, CBC with APC, Serum urea, Ma, K, CXR-PA, CBG, Blood CS,CSF
analysis, sputum AFBx2, ABG, PT, PTT. Patient was started on 1) ceftriaxone 2gm TIV q/20, 2) dexamethasone 8 mg,
TIV 30 min before giving ceftriaxone, 3) paracetamol 300 mg /IV q8, 4) Mannitol. She was referred to the service of
ophthalmology. TB DOTS. Cbg monitoring was done. On the 1 st hospital day (7/18), diet: gastric lavage until clear
then start of OF feeding. IVF: PNSS 1L x 100cc/hr. Still for the ff diagnostics: Cranial CT scan with contrast, blood CS
at 2 sites, CSF analysis, sputum PTB 2x, sputum GS/CS. For repeat CBC, BUN, crea,Na, K, PT, PTT, for ANA, ESR. For
referral to the service of neuro and rheuma for evaluation and management. For lumbar tap once with CT scan
results. On the 2nd hospital day (7/19), patient was seen by the service of ophtha, assessed to have essentially
normal fundoscopic findings at the time of exam. On the 3 rd HD (7/20), patient was put on soft diet with strict
aspiration precaution. IVF PNSS 1L x 80cc/hr. Mannitol was decreased to 100cc IV to OD; ceftriaxone 2g IV every 12
hours. Patient was started on clindamycin 300mg 1 cap every 6 hours. On the 4 th HD (7/21), mannitol was
discontinued, to continue other medications 1) omeprazole 40mg IV every 12 hours 2) hydroxyzine 25g 1 tab once a
day at bed time. Patient was started on Kalium durule 1 dose three times a day. The service of neuro assessed the
patient to have no active neuro abnormality; to rule out SLE. On the 5 th HD (7/22), patient was assessed as: t/c CNS
infection probably bacterial, probably intracranial spread secondary to chronic mastoiditis resolving; no
concomitant autoimmune disorder probably SLE; UTI. Kalium durule was discontinued. Omeprazole, shifted to
40mg/tab 1 tab OD prebreakfast. Patient was referred back to ENT for reevaluation. On the 6 th HD (7/23), patient was
on diet as tolerated. To continue mediations as ordered. On the 8 th HD (7/25) patient refused lumbar tap procedure
and signed the release from responsibility form. On the 9 th HD (7/26), patient may go home if with no fever. Take
home medications are as follows: 1) clindamycin 300mg 1 cap every 6 hours for 7 days 2) co-amoxiclav 625mg/tab 1
tab twice a day for 7 days 3) omeprazole 4mg 1 tab once a day 4) paracetamol 500mg 1 tab every 4 hours for fever.
To follow up after 2 weeks at IM-OPD. The rest of the hospital days were unremarkable.

IV.

MEDICATION:

Clindamycin; Ceftriaxone; Dexamethasone; Mannitol; Kalium durule; Hydroxyzine; Paracetamol

V.

FINAL DIAGNOSIS:
t/c CNS infection probably bacterial, probably intracranial spread secondary to chronic mastoiditis
resolving; no concomitant autoimmune disorder probably SLE; UTI

________________M.D
Resident on Duty