Alya/2y8mo/malay/girl

U/L eczema not on any follow up

non know drug allery

allergy to santan= generalize urticaria

immunization up to age, no additional vaccine

2nd hospitalization

1st admission at 3days of life for NNJ required phototherapy, no ET done

P/w

1)fever x 3/7

-onset 26/12/29 resolved since 28/12/19

-on and off

documetned temperature at home 39.1c

given syrup PCM 5hourly

no chills and rigor

no fitting episode

2) loose stool x 3/7

onset on friday 3/1/20

7x perday, moderate amount

watery + formed stool

3) blood in stool x 1/7

3x yesterday
bloodmixed mucus in stool, small amout

mother claim fresh blood

last blood in stool at 9pm

o/w no vomiting, no abd distension, no URTI symptoms, no rapid breathing, no bleeding tendency, no
bruises, no rashes, no foul smelling urine, no UTI symptoms,active as usual

+reduced urine output x 4/7

+ reduce oral intake x 1/7

today take bottle milk about 7oz, porridge, usually 5oz >5x/day

no history of sick contact at home

no history of recent travelling

no hisotyr of water activities recently

not from dengue prone area

no history of taking outside food

went to ED today day 3 of illness i/v/o bloodin stool

O/e alert, pink, not tachypneic, not irritable, good hydration, cring with tears, CRT < 2sec, warm
peripheries, good PV

T 37.3

Spo2 98%RA

RR 22

HR 147

Lungs clear, equal A/e

CVS S1S2
PA soft, non tender, no mass palpable

bowel sound present

Dengue combo test : NS1, Igm, IgG negative

USG abd no sonographic evidence of intussssception

FBC TWC 6.08 (N 43.7/ L48)

Hb 13

HCT 38.77

PLT 125

patient then admitted to the ward

In ward patient treat as Dysentery

upon review

last 4 x BO have blood in stool, currently in ward no blood in stool

sleeping, comfortable, not tachypneic, warm peripheries, CRT < 2sec, good pulse volume, hydration
good, normal skin turgor

PA soft

lung clear

CVS DRNM

Encourage orally

strict I/O charting

start IV cefotaxime 275mg TDS aim for at least 48hour

reduce IVD to half maintenance 22ml/hour

sent for stool C&S, stool feme, blood c&s

upon discharge

completed IV cefotaxime for 48hour

Blood C&S SFNG

stool rota pending

stool C&S pending

afebrile

no vomiting, no diarrhea

saturated under RA

oral intake improving

O/e

alert, active, warm peripheries, good PV, not tahypneic

lungs clear

CVS DRNM

PA soft

Bp 109/49

PR 88

Spo2 100 RA

T 36.8

plan

allow discharge