OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF PEDIATRICS Quirino Ave. corner Roxas Blvd., Malate, Manila
Patient’s Name: HILOTIN, Khane Alkhea Address: 246 Teresa Street, Sta. Mesa, Manila Age/Sex: 9 days/Female Date Admitted: June 5, 2008 Admitting Diagnosis: Hyperbilirubinemia probably secondary to ABO incompatibility CHD probably VSD Physician–in-charge: Dr. Nuñez/Arollado/Reyes Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
PATIENT DISCHARGE SUMMARY This is a case of a 9 day old female born full term to a 30-year old G2P2 (2-0-0-2) mother via NSD at a lying in clinic with no feto-maternal complications, who was brought in due to yellowish discoloration of the sclera. HISTORY OF PRESENT ILLNESS One week prior to admission, the patient was noticed to have yellowish discoloration of the eyes. She had good suck, cry and activity. She had yellowish stools and was not febrile. No consult was done, no medications were given. Five days prior to admission, the mother brought the patient to the local health center and was advised to expose her daughter to sunlight and to observe. However, the yellowish discoloration persisted and was even observed to be spreading to the soles; hence patient was referred to our institution. PAST MEDICAL HISTORY Previous Hospitalizations: None Pre-natal/Birth: Mother had 5 pre-natal check-ups. She did not have any illness or episodes of bleeding. There were no complications during delivery. Feeding History: Patient is mixed fed with breast milk and Bona 1:2 dilution. Immunizations: BCG x 1 dose; Hepatitis B vaccine x 1 dose Developmental History: At par with age FAMILY HISTORY Mother denied any heredofamilial illnesses. PERSONAL AND SOCIAL HISTORY: Patient lives with parents and one sibling. Drinking water is mineral water, unboiled. PHYSICAL EXAMINATION: General: Patient came in asleep, not in cardiorespiratory distress Vital Signs: HR = 112 RR = 59 Temp = 36.60C SHEENT: jaundiced form head to soles, atraumatic head, soft anterior and posterior fontanelles, icteric sclera, pink palpebral conjunctiva, moist oral mucosa, no cervical lymphadenopathy, nasoaural discharge Chest/Lungs: SCE, (-) retractions, clear breath sounds Cardiac: adynamic precordium,normal rate, regular rhythm, grade 3/6 holosystolic murmur best heard at the left lower parasternal border with no radiation. Abdomen: globular, NABS, soft, no tenderness, good skin turgor Extremities: full pulses, no cyanosis, no edema ASSESSMENT: Hyperbilirubinemia probably secondary to ABO incompatibility Congenital heart disease probably ventricular septal defect PLAN: For admission
Patient was admitted at the Pedia Ward Rm. 420 under the services of Drs. Nuñez/Arollado/Reyes. Labs Requested: CBC PC,CXR AP/L, baby’s blood type, mother’s blood type, Blood GSCS, 15-L ECG, total bilirubin, direct and indirect bilirubin. Medications: Ampicillin 170 mg/SIVP (100 mkd) q 12 hours and gentamycin 170 mg IV q 24 hours. Patient was placed on milk feeding with SAP. Patient was monitored VSq1. Course in the wards: On the 1st hospital day, milk feeding with SAP and burping was continued. IV access was maintained. Phototherapy with precaution was continued. Patient was for repeat TB, B1 and B2. Vital signs were monitored every 2 hours. On the 2nd hospital day, milk feeding with SAP and burping was continued. Phototherapy with precaution was continued. Medications were continued. Vital signs were monitored every 2 hours.
On the 3rd hospital day, milk feeding with SAP and burping was continued. Patient was subjected to intermittent phototherapy with precaution. Medications were continued. Vital signs were monitored every 2 hours. On the 4th hospital day, milk feeding with SAP was continued. Patient was subjected to intermittent phototherapy with precaution. Medications were continued. Patient was for repeat total bilirubin, B1 and B2 the following morning. Vital signs were monitored every hour. SUMMARY OF LABORATORY RESULTS Clinical Chemistry Total bilirubin Direct bilirubin Indirect bilirubin June 4 15.25 mg/dL 2.90 mg/dL 12.35 mg/dL June 7 227.55 umol/L 9.19 umol.L 218.4 umol/L
Blood typing: Baby: O+ Mother: O+ Complete Blood Cell Count with Platelet Count June 5 WBC 12.5 Neutrophils 38.4 Lymphocytes 55.8 Monocytes 4.1 Eosinophils 1.2 Basophils 0.5 RBC 5.10 HGB 18.6 HCT 54 Platelet 414