Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila Name: Gucan, Bb Boy Hospital No.: 630357 Age/ Sex: NB/ M Room No. 420 Neonatology Ward Address: B13 L 17 Phase II, Marites, Dasmariñas, Cavite Date of Admission: May 16, 2007 Admitting Diagnosis: Erythema Toxicum T/C TTNB vs Neonatal Pneumonia T/C Sepsis Neonatorum Dr. Guillera/ Dr. Wingsing 24-HOUR HISTORY This is a case of a 2-day-old male from Dasmariñas, Cavite who was subsequently admitted due to fast breathing. History of Present Illness Live baby boy born full term to a 23 year old G2P2 (2002) mother, 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 fast breathing, hence subsequent admission. Review of Systems Patient was apparently well; good suck, good cry, no vomiting, no jaundice, 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 4 prenatal check-ups. Mother had take in multivitamins and ferrous sulfate daily throughout her st pregnancy. Mother had UTI. She also had history of flu during her 1 month AOG for which she self-medicated with Neozep and Bioflu. She denied history of exposure to chemicals, radiation or had taken in teratogenic drugs. Natal Live baby boy born full term to a 23 year old G2P2 (2002) mother via NSD at OMMC Immunization: (+) BCG Feeding: Breastfed from birth up to present Physical Examination Patient is with fair activity, good cry, good tone and in respiratory distress. Vital Signs: HR 120 RR 92 T 36.1 SHEENT: Good skin turgor, no jaundice, (+) erythema on the chest, arms and face, no molding, no caput, no cephalhemtoma, anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no cleft lip/palate, (+) cyanotic lips 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, slightly cyanotic nailbeds, full and equal pulses Assessment: Erythema Toxicum T/C TTNB vs Neonatal Pneumonia 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 217cc x 24H to run at 9-10 ugtts/min by Soluset with strict I and O q shift monitoring. O2 support via funnel at 5-6lpm was applied. Diagnostics done were CBC with PC, CXR-APL, and Blood CS. Medications given were Ampicillin 150mg SIVP q12H (100mkd) and Gentamicin 15mg SIP q24H (5 mkd). Vital signs were monitored every 1 hour. st On the 1 hospital day, patient was afebrile, with fair activity, good cry, good tone, and still tachypneic. Present management was continued.
Pages to are hidden for
"420 Gucan 24H"Please download to view full document