420 Gucan 24H by dredwardmark


									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.

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