Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: SALIK, Baby Girl Address: Baseco, Port Area, Manila Age/Sex: NB/F Date Admitted: June 10, 2008 Admitting Diagnosis: Neonatal pneumonia vs. Transient Tachypnea of the Newborn Physician–in-charge: Dr.Nunez/Villa/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 640489
CLINICAL ABSTRACT This is a case of a live baby girl born full term to a 25 year old G3 P3 (3-0-0-3) mother via LTCS secondary to frank breech. PAST MEDICAL HISTORY Pre-natal: Mother had 2 pre-natal check-ups adone at Tandang Sora Health Center. No laboratory examinations done except ultrasound. She denies presence of any comorbid factors. st Birth: Patient was born to a 25 year old G3 P3 (3-0-0-3) mother via LTCS secondary to frank breech. APGAR at the 1 minute was 9, at 5 minutes was 9. Ballard score was 38 weeks. Birth weight was 2.5 kg, birth length was 39 cm. Post-natal: Patient was active, with good cry and good tone. Patient had retractions, grunting and apnea.
FAMILY HISTORY Mother denied any heredofamilial disease. PHYSICAL EXAMINATION: General: good activity, good cry, good tone, not in cardiorespiratory distress. Vital Signs: 0 HR = 170 bpm RR = 50 cpm Temp = 36.5 C Anthropometrics: Weight = 1.25 kg Length = 47 cm Head circumference = 33 cc 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, clear breath sounds Cardiac: adynamic precordium, normal rate, regular rhythm, (-) murmur Abdomen: globular, NABS, soft, no tenderness, (-) masses Extremities: grossly normal extremities, full equal pulses, (-) edema, (-) cyanosis, (-) polydactylism, (-) syndactylism, (-) club foot Reflexes: (+) Moro, (+) sucking, (+) grasping ASSESSMENT: Neonatal pneumonia vs. Transient tahypnea of the newborn
Patient was admitted to the NICU under the service of Drs. Nunez/Villa/Manalo. Patient was placed on NPO temporarily. Umbilical catheter was inserted. IVF given was D10W 150 ml to run for 24 hours at 6-7 ugtts/min. O2 support was given at 8 lpm. Laboratories requested were CBC/PC, CXR-APL, bood typing and blood CS. Therapeutics:ampicilling 125 mg SIVP q 12 hours (100mkd), gentamycin 12.5 mg SIVP q 24 hours (5 mkd) and aminophylline 5 mg loading dose (8 mkd) then maintained at 5 mg BID (2 mkd). Patient was kept normothermic via droplight. Vital signs were monitored every hour.