Delantar 24 Hr Hx by dredwardmark


									Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila

Patient’s Name: Delantar, Baby Boy Address: 2239 Rd 10, Fabre St., Sta. Ana Manila Age/Sex: NB/male Date Admitted: May 19, 2008 Admitting Diagnosis: Swallowed Maternal Blood vs. Sepsis neonatorum Physician–in-charge: Dr. Troncales/Dr. Salloman/Dr. Manalo Clerk-in-charge: Erum/Fernando/Figueras/Fuentes/Cuvin

Hospital No. Room No. Infirmary-Room321

24 HOUR HISTORY This is a case of a new born baby boy born preterm to a 22 year-old G1P1 (0-1-0-1) via NSD at OMMC. HISTORY OF PRESENT ILLNESS: Present condition started few minutes after delivery of the baby when patient had vomiting episodes about 2-3 bouts, hence admitted. REVIERW OF SYSTEMS: N/A PAST MEDICAL HISTORY: st Pre-natal: Mother had a complete prenatal check-up, from 1 month of pregnancy until before the delivery of the baby. The patient had UTI at her month of pregnancy. There was no fetomaternal complications noted. Birth: born full preterm to a 22 year-old G1P1 (0-1-0-1) mother via NSD. Post-natal: good cry, good suck, pinkish skin, no breathing difficulty, no seizure. (-) cyanosis, (-) respiratory distress, (-) convulsion st Immunization: Hepa B-1 dose FAMILY HISTORY/ PERSONAL AND SOCIAL HISTORY: ( ) HPN ( ) DM ( ) allergy ( ) bleeding disorders PHYSICAL EXAMINATION: General: asleep, not in cardiorespiratory distress Vital Signs: 0 HR = 140 RR = 40 Temp = 37 C Anthropometric: HC = 30cm CC = 30cm AC = 31cm BW=2.3kg BL=45cm HEENT: anicteric sclera, pink palpebral conjunctiva, no cervical lymphadenopathy Chest/Lungs: symmetric chest expansion,no retractions, clear breath sounds, no wheezes Heart: adynamic precordium, normal rate and regular rhythm, no murmurs Abdomen: flat, normoactive bowel sounds, no tenderness Extremities: grossly normal, full and equal pulses, no cyanosis, no edema ASSESSMENT: Swallowed Maternal Blood vs. Sepsis neonatorum PLAN: For admission Course in the Wards: st On the 1 HD, the patient was on D10W 185cc x 24 hours at a rate of 7-8ugtts/min. He was placed under droplight and was maintained normothermic (36.5-37.5°C). IV meds include ampicillin115mg SIVP Q12 and amikacin 34mg SIVP Q24. Vital signs monitoring every 4 hours.

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