Laboratory or Reference Actual Results Interpretation

Diagnostic Procedure Values

COMPLETE BLOOD COUNT (CBC)

HGB 10.9-15.0g/dL 11.2 g/dL It is normal

(112g/L)

HCT 31-41% 34.5 It is normal

WBC 4.0-12.0 10^3/μL 15.7 It is slightly elevated, indicating that the body is producing
more white blood cells to fight an infection

RBC 3.50-6.50 4.53 It is normal

10^5/μL

PLT 250-450 10^3/μL 420 It is normal

RDW 11.8-14.5% 15.6 It is slightly elevated, which is an indication of nutrition

deficiency, such as deficiency in iron, folate or vitamin B-12

Gran 1.5 – 8.5 x 10.3 It is slightly elevated, which may indicate a number of issues
10^9/L such as infection or some types of autoimmune disease.

Lymp 3.0-9.5 4.5 It is a normal reading

Erythrocyte Sedimentation Rate Test (ESR Test)

Reference Values Results Interpretation

1-13 mm/hr 95mm/hr It is extremely high, which is related to the spike of an inflammatory
condition

C-Reactive Protein Test (CRP)

Reference Values Results Interpretation

3.0-10.0 slightly elevated 22.0 It is moderately elevated, which signifies infection or an

inflammatory condition.
10.0-100.0 moderately elevated

100.0-500.0 elevated
URINALYSIS

Reference Results Interpretation

Values

Color Yellow (light/pale Yellow It is normal

to dark/deep
amber)

Transparency Clear or cloudy Clear It is normal

pH 4.5-8 7 It is within the normal range

Sp. Gravity 1.005-1.025 1.000 It is slightly below the normal range, hence it could indicate that the
patient is either properly hydrated or the worst case scenario is that the
patient has diabetes or damage to the kidney/kidney failure.

Albumin N/A Positive Having positive albumin is an indication of kidney disease/damaged

kidney

Sugar N/A Negative Having negative sugar may be the result of a normal blood glucose level
or a dangerously low blood glucose level (hypoglycaemia)

Pus Cells 0.00-3.00 hpf 1-3 hpf It is within normal range

 I.

Medical Regimen Rationale

March 22, 2022 - 10:30AM

Admit patient to ROC under the service of Dr. ● To monitor the condition of the patient
Villas

Secure consent for admission and management ● To obtain informed consent

Monitor and record VS every 4 hours ● To further observe the VS of the patient and for early detection of
problems that may arise
Monitor and record I and O every shift
● To determine patient’s fluid levels

Diet Instruction: DFA (Diet For Age) ● To provide the patient with the diet appropriate for their age (1
year and 6 months old)

Diagnostics:
● CBC with platelet count ● To analyze and determine an increase or decrease in white
blood cells, red blood cells and the number of platelets in the
patient’s blood.
● To prevent possible complications by early detection

● Urinalysis ● To detect and manage infections concerning the urinary tract

since Kawasaki disease can affect kidneys and urinary tract
Start venoclysis with D5.3 NaCl 500cc at 60cc/hr ● To aid in replacement or maintenance of fluid and electrolytes
● To help in preventing dehydration

Administer:
● Ampicillin 250mg TIV every 6 hours ANST ● To treat certain infections that are caused by bacteria and
(after negative skin test) infections of the throat sinuses, urinary tract and other organs

● Paracetamol 100mg / 1.2ml every 4 hours

RTC (round the clock) ● To ease pain and treat fever

● Paracetamol 90mg TIV every 4 hours PRN

(as needed) for temperature ≥ 38.5C

Refer accordingly ● To notify attending healthcare team on the patient’s situation

March 23, 2022 - 9:00AM

Maintain IVF with D5IMB 500cc at SR for 2 cycles ● To aid in maintenance of fluid and electrolytes especially to
patients who need calories and hydration.

Diagnostics:
● Repeat Urinalysis ● To assess if there are improvements and to detect further
complications

● ESR test (erythrocyte sedimentation rate ● To detect or reveal inflammatory activity in the patient’s body
test)

● To find or monitor conditions that cause inflammation

● CRP test (C-reactive protein test)
 ● 2D echocardiogram with doppler ● To provide the physician with information like the functioning of
heart, diagnose the malfunctions, if any, and plan the treatment
for the developing disease
Administer:
● Paracetamol PO RTC for 2 doses then
PRN (as needed) ● To relieve pain and treat fever

● Cetirizine oral drops 1ml every 12 hours ● To treat symptoms of Kawasaki disease, specifically symptoms
of allergies (e.g. red and itchy eyes)

Instruct to use mild, fragrance-free soap ● To prevent further infection of the skin or rashes

Apply petroleum jelly or any water soluble to lips if ● To aid one of the symptoms of Kawasaki disease: dry, cracked
not bleeding lips

Refer accordingly ● To notify attending healthcare team on the patient’s situation

March 24, 2022 - 10:00AM

Continue IVF D5IMB 500cc at SR for 3 cycles ● To continue hydration and prevent dehydration

Shift Ampicillin to Cefuroxime 100g / 2.5ml every ● To treat a variety of infections

12 hours
Patient for IVIg infusion at 2g/kg for 10 hours ● Intravenous immunoglobulin infusion is used to treat various
autoimmune and infectious diseases

Check VS before infusion ● To obtain baseline data and observe for any adverse reactions
that may occur

Watch out for hypersensitivity reaction ● To identify adverse effects upon the infusion and provide
immediate interventions

Start administration of aspirin 20mg/kg/day for 4 ● To reduce fever and relieve mild pain
doses

Perform TSB (Tepid Sponge Bath) ● To promote dispersal of body heat and lower the body
temperature

Perform PROM (Passive Range of Motion) every4 ● Performing passive range of motion exercises will help in
hours during waking hours only engaging the muscles and keep the joints of the patient flexible

Refer to Dr. Go for Pedi-cardio co-management ● To further monitor and observe the patient’s condition

Refer accordingly ● To notify attending healthcare team on the patient’s situation

7:00PM (Patient was seen and examined;

patient is stable at the moment)

Inform doctor once ready for discharge ● To gather information regarding medications to be taken at home
and knowledge about follow-up check-ups