Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila Name: Escosis, Bb Boy Hospital No.: 630318 Age/ Sex: NB/ M Room No. 420 Neonatology Ward Address: Baseco Port Area, Manila Date of Admission: May 16, 2007 Admitting Diagnosis: Hyperbilirubinemia R/O ABO Incompatibility T/C Sepsis Neonatorum Dr. Guillera/ Dr. Wingsing 24-HOUR HISTORY This is a case of a 4-day-old male from Baseco, Manila who was admitted due to jaundice. History of Present Illness Live baby boy born full term to a 31 year old G8P7 (7017) mother, 38-39 weeks AOG via NSD at this institution. Patient was essentially normal at birth with an AS 9 and 9 on 1 and 5 mins respectively until few hours prior to admission, patient had generalized jaundice, hence subsequent admission. Review of Systems Patient was apparently well; no fever, no cough, no colds, no difficulty of breathing, no difficulty in urination, no seizures nor convulsions. Personal/ Social History Prenatal Patient’s mother had a total of 5 prenatal check-ups. She did no take any multivitamins but had taken ferrous sulfate daily. Mother had UTI during the 7month AOG and was given with Amoxicillin to be taken for 7 days. She also had history of colds dur ing her th 9 month AOG. She denied history of exposure to chemicals, radiation or had taken in teratogenic drugs. Natal Live baby boy born full term to a 31 year old G8P7 (7017) mother via NSD at OMMC Immunization: (+) Hep B 1 Feeding: Breastfed from birth up to present Physical Examination Patient is with good activity, good cry, good tone and not in cardiorespiratory distress. Vital Signs: HR 118 RR 46 T 36.1 Arthropometric Measurements: L 53cm W 3.35kg HC 36cm CC 35cm AC 32cm SHEENT: Good skin turgor, with jaundice up to the sole, no rashes, (+) molding, no caput, no cephalhemtoma, anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no cleft lip/palate Chest/ Lungs: symmetric chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: Globular, normoactive bowel sounds, no masses, soft, nontender Extremities: Grossly normal, no edema, no cyanosis, full and equal pulses Assessment: Hyperbilirubinemia R/O ABO Incompatibility T/C Sepsis Neonatorum Plan: For admission Course in the Wards: Upon admission at Pedia-Ward Room 420 under the service of Drs. Guillera/Wingsing, patient was on breastfeeding as tolerated and hooked to D5IMB 270cc x 24H to run at 11-12 ugtts/min by Soluset with strict I and O q shift monitoring. Diagnostics done were CBC with PC, CXR-APL, BT, MBT, TB B1 B2, and Blood CS. Medications given were Ampicillin 170mg SIVP q12H (100mkd) and Gentamicin 20mg SIP q24H (5 mkd). Patient was placed under phototherapy with precaution. Vital signs were monitored every 1 hour. st On the 1 hospital day, patient was afebrile, with good activity, good cry, good tone, not in cardiorespiratory distress. Present management was continued.
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