BENIGN FEBRILE SEIZURES CP di ko sure ang naka red

Name: Xeah Yzabella U. Sasil Age: 3 months old Sex: Female

Religion: Roman Catholic Room #: 303A Nationality: Filipino
Birthday: November 1, 2023 Hosp #: 1019103 Case #: 5447
Father: Jay Archie Sasil Mother: Leah Joy Utbos
Height: 60 cm Weight: 6.5 kg Diet: Diet for Age
Hospital Plan: PhilHealth
Address: Purok II Lanton, Brgy. Apopong, General Santos City, South Cotabato
Attending Physician: Dr. Mayrose C. Gilbuena / Dr. Queenie C. Gilbuena
Admission date and time: February 12, 2024 4:25PM
PHYSICAL EXAM
 Irregular
 Deep
Airway and breathing and circulation  Labored breathing
 Non-productive cough
 Bounding pulse
Cognitive  Awake and alert

 Pale
Skin  Cyanotic
 Mottled skin

Abdomen  Essentially normal

Rectal  Essentially normal

 Pale conjunctivae
Others
 Dry mucous membranes

History of Present Illness

3 days PTA patient had sudden onset fever with cough and cold, wherein they
self-medicated with paracetamol to some relief. Afternoon PTA patient had fever then
suddenly had a seizure which prompted them to self-admission.
Past Health History
No known comorbidities; No allergies
Admission symptoms:
  Fever
 Cough
 Nausea, Vomiting, and Diarrhea (5x 1 day PTA 02/11/2024

Admitting diagnosis:
 T/C Benign Febrile Seizure
 T/C PCAP – MR (Pediatric Community Acquired Pneumonia – Moderate Risk)
Triage – STAT 1
Vital signs
 RR: 44 breaths per minute
 HR: 189 bpm
 Temp: 38.6֯C

MEDICATIONS IVF
Paracetamol 100mg IVTT q4h PRN T ≥ 38֯C

Diazepam 1.3mg Slow IVTT PRN for frank seizure

D50.3 500 mL 30 cc/hr
Salbutamol ½ nebule + 1 mL NSS q6h
D5IMB 500 mL 30 cc/hr
Ceftriaxone 650 mL IVTT OD – ANST (650 mg/vial)

O2 6L/min via Face Mask (dc 02/13/2024)

LABORATORY RESULTS
(Electrolytes)
RESULT REFERENCE
Sodium 136 135 – 148 mEq/L
Potassium 3.77 3.50 – 5.30 mEq/L
Chloride 98.00 – 107.00 mEq/L
Ionized calcium 1.13 – 1.32 mmol/L

(Complete Blood Count)

 RESULT REFERENCE
Hemoglobin 99 M: 135 – 180 g/L F: 120 – 150 g/L
Hematocrit 0.30 M: 0.40 – 0.54% F: 0.35 – 0.49%
RBC 3.76 M: 4.20 – 6.0010^12/L F: 3.80 – 5.20 10^12/L
MCV 80.0 80 – 100
MCH 25.9 26 – 34
MCHC 324 320 – 360
RDW 13.4 11.6 – 14.0
WBC 9.39 4.0 – 10
Neutrophil 0.56 0.50 – 0.70
Lymphocyte 0.40 0.18 – 0.42
Monocyte 0.09 0.2 – 0.11
Eosinophil 0.01 0.1 – 0.3
Basophil 0.00 0 – 0.2
Platelet 451 150 – 450

RADIOLOGIC TEST
(Chest APL – February 13, 2024 9:32 AM)
Findings

There are interstitial infiltrated seen in both hilar areas

Pulmonary vascular markings are within normal
Trachea is midline. Heart is not enlarged
Diaphragm and costophrenic sinuses are intact
Bony thorax is unremarkable. No other significant findings of note

Impression
~ Pneumonia