Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: DORADO, Baby Girl Address: 1641 P. Benito Street, Brgy. Kasilanan, Makati City Age/Sex: NB/F Date Admitted: June 15, 2008 Admitting Diagnosis: T/C Sepsis neonatorum, early onset Clavicular fracture Physician–in-charge: Dr.Nunez/Villa/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 640625
48 HOUR HISTORY This is a case of a live baby girl born full term to a 33 year old G3 P3 (3-0-0-3) mother via NSD. PAST MEDICAL HISTORY Pre-natal: Mother had a total of 7 pre-natal check-ups done at Casilanan Health Center.First check-up was at 2 months AOG, last check-up was at 9 months AOG. Laboratory examinations done were CBC, blood typing, urinalysis and ultrasound. She had UTI was 5 months AOG and was treated with amoxicillin TID for 7 days. Birth: Patient was born full term to a 33 year old G3 P3 (3-0-0-3) mother via NSD. APGAR at the 1st minute was 9, at 5 minutes was 9. Ballard score was 37-38 weeks. Birth weight was 3.45 kg, birth length was 47 cm. Post-natal: Patient was active, with good cry and good tone.
FAMILY HISTORY Mother denied any heredofamilial disease. PHYSICAL EXAMINATION: General: good activity, good cry, good tone, not in cardiorespiratory distress. Vital Signs: HR = 160 bpm RR = 40 cpm Temp = 36.50C Anthropometrics: Weight = 3.45 kg Length = 47 cm Head circumference = 33 cm Chest circumference = 32.5 cm Abdominal circumference = 31 cm SHEENT: pink color, good skin turgor, (-) rash, (-) hematoma, (-) desquamation, (-) caput, (-) molding, (-) craniotbes, (-) cephalhematoma, (-) facial asymmetry, (-) conjunctivitis, (-) eye discharge, patent nose, (-) cleft lip or palate Chest/Lungs: (+) breast bud, (+) clavicular fracture, normal rate, regular rhythm, clear breath sounds Cardiac: adynamic precordium, normal rate, regular rhythm, (-) murmur Abdomen: globular, NABS, soft, no tenderness, (-) masses Extremities: grossly normal extremities, full and equal pulses, (-) edema, (-) cyanosis, (-) polydactylism, (-) syndactylism, (-) club foot Reflexes: (+) Moro, (+) sucking, (+) grasping ASSESSMENT: T/C Sepsis neonatorum, early onset Clavicular fracture PLAN: For admission
Patient was admitted to the NICU under the service of Drs. Nunez/Villa/Manalo. Heplock was inserted. Laboratories requested were CBC with PC, blood typing, total blirubin, B1 and B2 and blood CS. Therapeutics:ampicillin 200 mg SIVP q 12 hours (58 mkd), gentamycin 17 mg SIVP q 24 hours (4.9 mkd). Patient was exposed to continuous phototherapy with proper shields given to the eye and genitalia. Vital signs were monitored every hour. On the 1st hospital day, milk feeding with SAP was continued. Phototherapy with proper shields was continued. Medications were continued. Vital signs were monitored every hour. On The 2nd hospital day, milk feeding with SAP was continued. Vital signs were monitored every hour.