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
PATIENT DISCHARGE SUMMARY 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 had good suck and good cry. Patient was for repeat CBC with PC tom. Follow-up blood culture and continue medications. On the third hospital day, patient,s HR 130, RR 40, present wt 2.6kg, birth wt 2.65kg. Patient was awake, with good cry, flat anterior fontanelle, CBS, equal chest expansion, no adventitious sounds, adynamic precordium, NRRR, (-) murmur, soft abdomen, (-) palpable mass, full equal pulses, (-) cyanosis, jaundice down to soles. Present working impression: Sepsis Neonatorum PROM for 28 hours. Patient may have milkfeeding as tolerated, may cont Ampicillin D2(100mkd), Gentamycin D2 (5mkday), TB, B1, B2 was requested. Maternal BT and baby BT was also requested. Patient was also for blood culture c/o relatives because no Bactec bottle available at the lab. Patient was for continuous phototherapy with eyeshield.
On the forth hospital day, patient was active, with good cry, good suck, (-) vomiting (+) jaundice, MBT: A+. Patient was continued on medications, continued on MF as per demand, for facilitation of maternal blood type and baby blood type, total bilirubin, for continued phototherapy with proper eyeshield. On the fifth hospital day, patient was active, (-) jaundice and good suck. Patient was for continue medications, for CBC that day, discontinue phototherapy and for watching out rebound jaundice. On the 6th hospital day, patient was active, has good cry, good suck. Patient has may go home orders, patient was given vitamin K 1 mg thru IM prior to discharge, for OPD follow-up 1 pm next Friday.