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  • BLH Case Profile

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    Dianne Ulanday
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    Patient Cassie Jade Dimacali, a 3 month old female, was admitted to the hospital on November 15, 2023 at 12:51AM with a chief complaint of difficulty breathing. She has a history of being born prematurely via c-section and staying in the NICU for over a month. She presented with cough, cold, and jaundice. Her admitting diagnosis was sepsis and cholestasis. Her physical exam showed jaundiced sclera and skin with otherwise normal findings. The clinical impression was sepsis and possible pneumonia.

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    Patient Cassie Jade Dimacali, a 3 month old female, was admitted to the hospital on November 15, 2023 at 12:51AM with a chief complaint of difficulty breathing. She has a history of being born prematurely via c-section and staying in the NICU for over a month. She presented with cough, cold, and jaundice. Her admitting diagnosis was sepsis and cholestasis. Her physical exam showed jaundiced sclera and skin with otherwise normal findings. The clinical impression was sepsis and possible pneumonia.

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    © All Rights Reserved
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    10 views1 page

    BLH Case Profile

    Uploaded by

    Dianne Ulanday
    Patient Cassie Jade Dimacali, a 3 month old female, was admitted to the hospital on November 15, 2023 at 12:51AM with a chief complaint of difficulty breathing. She has a history of being born prematurely via c-section and staying in the NICU for over a month. She presented with cough, cold, and jaundice. Her admitting diagnosis was sepsis and cholestasis. Her physical exam showed jaundiced sclera and skin with otherwise normal findings. The clinical impression was sepsis and possible pneumonia.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    Case No: 2300000699

    Patient’s No: 2300001199

    Name: Dimacali, Cassie Jade


    Address: Binangonan, Rizal
    Age: 3 months
    Date of Birth: August 6, 2023
    Religion: Catholic

    Admission Date: November 15, 2023 12:51AM


    Physicians: Dr. Regio, MD and Dr. Manuel, MD
    Chief Complaint: DOB
    Admitting Diagnosis: T/C Sepsis, Cholestasis
    Room: Semi Private E1

    History: Born to 30/F to G2P2 at 31 weeks via CS stayed at NICU for 1 month and 3 days.
    Patient improved but had cough and cold, and associated with jaundice. Patient was being
    cared of attending physician and was given medication persistent, prompted admission.

    Past Medical History: Cholestasis; ^B2 (increase B2 hematology)


    Medications: Cefixime
    Review of Systems: (+) Jaundice

    Physical Exam:
    CR/PR: 130 Temp: 36.5 Height: 47 cm
    RR: 44 O2: 93% Weight: 3.6kg
    HEENT: (+) slightly ________ sclera
    Respiratory: _______
    Cardiac: AP, _______, (-) murmur
    Abdomen: soft, WABS
    Extremities: ______, (+) Jaundice
    Neurologic: ________
    Clinical Impression: T/C sepsis
    *Pneumonia

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