Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: BARADAN, Bb. Girl Address: Tondo, Manila Age/Sex: NB/F Date Admitted: June 28, 2008 Admitting Diagnosis: T/C Sepsis Physician–in-charge: Dr.Nunez/Villa/Manalo Clerk-in-charge: Fabian/Ilarde/Ingles/Item/Junsay
Hospital No. 640963
48 HOUR HISTORY This is a case of a live baby girl born preterm to a 24 y/o G3 P3 (2-4-0-6) mother 35-36 wks AOG via NSD. PAST MEDICAL HISTORY Pre-natal: Patient’s mother had a total of 7 pre-natal check-ups, done at Ospital ng Tondo, first prenatal check-up was at 3rd month AOG, last check-up was at June 27, 2008. Mother had cols at 2nd month of AOG but did not take any medications. Patient mother took multivitamins and ferrous sulfate during her pregnancy. Birth: Patient was born preterm via NSD. APGAR at the 1st minute was 4, at 5 minutes was 8. Ballard score was 35-36 weeks. Birth weight was 2.65 kg, birth length was 49 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 bpm RR = 50 cpm Temp = 36.50C Anthropometrics: Weight = 2.65 kg Length = 49 cm Head circumference = 32 cm Chest circumference = 32 cm Abdominal circumference = 28 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: t/c sepsis PLAN: For admission
Patient was admitted to the NICU under the service of Drs. Nunez/Villa/Manalo. Patient may have milkfeeding as tolerated. Do routine newborn care. Laboratories requested were CBC with PC, blood typing and blood CS. May start on heplock. Therapeutics: Ampicillin 150mg IV q12 (100mkd), Gentamycin 13mg IV q24 (5mkd), Keep thermoregulated. Monitor VSq1. COURSE IN THE WARDS On the first hospital day, patient had good suck, (+) 1 episode of vomiting in the morning, soft abdomen. Patient was for continued medications and follow-up blood culture. On the second hospital day, patient was for repeat CBC with PC tom. Follow-up blood culture and continue medications.