jon's Medical Abstract

Philippine Children's Medical Center

Patient name: Jon Angelo Modesto Viado
Age: 1 yr 7/12 months
Sex: Male
(Medical Abstract - 10th Confinement)

Admission Diagnosis: Hypoxic Ischemic Encepalopathy, GERD (Gastro Esophageal Reflux Disorder) Seizure Disorder, Mild Cerebral Palsy, S/P Tracheostomy

History of Present Illness:
Patient is a known case of CP secondary to Hypoxic Ischemic Encepalopathy initially presenting with seizures. Also diagnosed with GERD, s/p Tracheostomy last May 2009.
Patient is scheduled for Tracheostomy replacement every 3 months.

Laboratory Examinations:
ABG
Serum Electrolytes
CBC/Platelet Count
Urinalysis

Medications: (maintenance)
Phenobarbital
Clonazepam
Lanzoprazole
MVS
FeSO4
Zinc Drops

Final Diagnosis:
CEREBRAL PALSY (MILD), G.E.R.D, H.I.E.

Operation Performed and/or Special Procedure: Change of Tracheostomy Tube

Patient was discharged in an IMPROVED condition.

* Jon was admitted in ICU from March 26- July 28 2009, 123 days in I.C.U.
* Jon Angelo is on life support for more than 10 months now