Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: BOGO Bb. Boy Hospital No. 641063 Address: 1913, F. Munoz st., Malate, Manila Age/Sex: NB/F Date Admitted: July 2, 2008 Admitting Diagnosis: Live baby boy, born full term to a 18 y/o, G1P1 (1001) mother, 39wks AOG via NSD, AS 9,9, BS 39, BW 2.5kg Physician–in-charge: Dr.Juico/Nicolas/Ang Clerk-in-charge: Fabian/Ilarde/Ingles/Item/Junsay
48 HOUR HISTORY This is a case of a Live baby boy, born full term to a 18 y/o, G1P1 (1001) mother, 39wks AOG via NSD, AS 9,9, BS 39, BW 2.5kg PAST MEDICAL HISTORY Pre-natal: Patient’s mother had a total of 5 pre-natal check-ups, done at OMMC. Mother had no maternal illnesses. Patient mother took multivitamins and ferrous sulfate during her pregnancy. Birth: Patient was born Full term via NSD. APGAR at the 1st minute was 9, at 5 minutes was 9, Ballard score was 39 weeks. Birth weight was 2.50 kg, birth length was 48 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 = 150’s bpm RR = 40’s cpm Temp = 36.50C Anthropometrics: Weight = 2.50 kg Length = 48 cm Head circumference = 30 cm Chest circumference = 29 cm Abdominal circumference = 29 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, (-) subcostal retractions, 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: Sepsis Neonatorum PLAN: For admission
Patient was admitted to the NICU under the service of Drs. Juico/Nicolas/Ang. Patient was monitored q2. Input and output was monitored accurately. Place under droplight and maintain normothermic. Patient was NPO, Hgt now then q 8 hours IVF: D10 150cc X 24 hours @ 6-7 ugtts/min. Laboratories requested were CBC with PC, blood CS, PFA to include chest. Therapeutics: Ampicillin 150g/ SUP q12 (120mkd), Gentamycin 12g/SUP q24 (5mkd),Dopamine 4mg + 100cc D5w to run @ 10 ugtts/min (use infusion pump) Keep thermoregulated. Refer is HR <30 bpm. COURSE IN THE WARDS: On the 1st hospital day, patient had phlebitis @ Left arm, TFI=400cc/kg. Patient was continued on present medications, for reinsertion of IV line, IVF-TF was D10W 215, Na 3, K 2.5, Ca gluconate 5, for a total of 225cc x 24 hours to run at 9-10 ugtts/min, replace OGT lossess with equal amount of PNSS. On the 2nd hospital day, there was no vomiting, (+) CBS, ECE, (-) OGT output, TFI: 100cc/kg. Patient was continued with medications, start milkfeeding at 3cc q3hours, refer if patient would vomit. IVF-TF was D5IMB 210cc at IVF rate at 8-9ugtts/min. continue NB care. In the afternoon, patient was active (-) vomiting RR40s, remove OGT, continue MF at 5cc q3 with SAP (elevate head at all times). WOF: vomiting, abdominal distention.