Reloj, Jernelyn P. III-B Dr. Alabastro PEDIATRICS II
January 9, 2006
Informant: Mother % Reliability: 90%
I. General Data L.N. is a 13 days old, male, Filipino, Roman Catholic, born in Punta, Sta. Ana, Manila on December 27, 2005. He is presently residing at 1880-B Mayon St. Punta, Sta. Ana, Manila. He was admitted for the first time at OMMC on January 5, 2005 at about 9:00 am.
II. Chief Complaint Bleeding Umbilical Stump
III. History of Present Illness 17 hours PTA, the mother noticed that the patient’s umbilical stump was bleeding. According to her, it was continuously bleeding but the blood flow is of small quantity. She immediately cleaned it with Povidine Iodine (Betadine) many times but the bleeding did not stop. This prompted her to consult to the midwife who recommended her to apply Fusidic acid cream 2% (Fucidin) onto the patient’s umbilical stump. After several applications, the bleeding still would not stop, so the mother discontinued using it. The patient has no history of fever, vomiting and dyspnea. There were no other sites of bleeding noted. 13 hours PTA, the patient’s umbilical stump is still continuously bleeding, this time, in increased blood flow quantity. The mother only cleaned it with Povidine Iodine (Betadine) but it didn’t stop the bleeding. 9 hours PTA, the patient’s umbilical stump was still continuously bleeding. The mother then decided to seek consult to PGH. According to the doctor, it was just a peeled wound crust in the umbilicus and so the doctor only cleaned the wound and put a thick gauze pad on the patient’s umbilicus, and then sent them home. There were no other procedures done and no medications were given to the patient. The mother was not sure if the bleeding did stop because she did not inspect it anymore and went to sleep. 3 hours PTA, when the mother checked the wound dressing, she said it was already soaked with blood. She also noticed some drops of blood on the sides of the patient’s abdomen. She only cleaned the umbilicus and changed the wound dressing but it didn’t stop the bleeding. 1 hour PTA, patient’s umbilical stump is still continuously bleeding. The mother rushed him to OMMC and was subsequently admitted.
IV. Review of Systems CONSTITUTIONAL: No weight loss, no loss of apetite. No fever, no chills. HEAD: No gross deformity, no signs of trauma, no mass, no loss of hair. EYES: No excessive lacrimation. EARS: No discharge. NOSE: No epistaxis, no nasal obstruction. MOUTH: No mouthsores. INTEGUMENT: No rashes, no dryness, no change in color. RESPIRATORY: No dyspnea, no orthopnea, no cough. CARDIAC: No palpitations, no cyanosis. GASTROINTESTINAL: No diarrhea, no hematemesis, no melena. Yellow stool. HEMATOLOGIC: No bleeding tendencies, no easy bruising, no anemia. ENDOCRINE: No temperature intolerance. NEUROMUSCULAR: No tremors, no seizures. MUSCULOSKELETAL: No rigidity.
V. Past Personal History A. Prenatal History The patient’s mother had no prenatal check-up. She took folic acid one a day for 9 months. She is a non-smoker and non-alcoholic beverage drinker before and during the pregnancy. She did not contract any illness except for fever which she selfmedicated with Paracetamol (Biogesic) 500 mg tab. B. Birth History The patient was born full term to a G3P3 (3-0-0-3) mother at OMMC, normal spontaneous delivery with head presentation. Labor lasted for 30 minutes. The patient’s birth weight was 7 lbs. The patient had good cry upon delivery and no fetomaternal complications were noted. C. Neonatal History There were no congenital defects, no cyanosis, no pallor, no jaundice, no hemorrhage, no birth injuries, and no convulsions noted after delivery.
D. Feeding History The patient was breastfed since birth. At night, he was breastfed by his mother that lasts for 30 minutes per feeding. E. Immunization History The patient had BCG vaccination after birth at a nearby health center. F. Past Medical History The patient had no previous illness, trauma, accidents and injury.
VI. Family Medical History The patient’s father, 35 years old, and his mother, 31 years old, are apparently well. Two other siblings are apparently well. No heredofamilial diseases.
VII. Social History The patient’s father is a helper. He is an alcoholic beverage drinker, drinks about 2x a week and smokes 3 ½ pack years. His mother, a housewife, is a non-smoker and non-alcoholic. The patient lives with 2 other families, total of 12 people, in a three-storey concrete house with one pour-flush type toilet. Garbage is collected everyday. They drink mineral water while for other purposes water comes from NAWASA. There were no environmental hazards and prevalent communicable diseases in the community.
VII. Physical Examination GENERAL SURVEY: The patient is asleep, supine, not in cardiorespiratory distress with IV line in the right hand. VITAL SIGNS (upon admission): BP: not taken PR: 158 bpm RR: 42 cpm Temp: 36.5˚C Ht: 52 cm Wt: 3.7 kg 2 BMI: 13.68 kg/m VITAL SIGNS (upon PE): BP: not taken PR: 141 bpm RR: 52 cpm Temp: 36.8˚C Ht: 52 cm Wt: 3.7 kg 2 BMI: 13.68 kg/m ANTHROPOMETRIC DATA: Head Circumference: 35 cm
Chest Circumference: 39 cm Abdominal Circumference: 41 cm Midarm Circumference: 10 cm SKIN: Patient has fair complexion. The skin is dry and has fair skin turgor. There is no clubbing of nails or signs or signs of cyanosis and jaundice. No sores or rashes noted. HEAD: Symmetrical. No gross deformities. Evenly distributed hair. FACE: Symmetrical. No pertinent facie. No scars. EYES: Equal distribution, color and texture of eyebrows. EARS: No gross deformity, no discharge. NOSE: Symmetrical. No congestion of nasal pathway. MOUTH: Lips are symmetrical and pink. Mucosa is pink. No sores. NECK: No masses. No scars. THORAX AND LUNGS: Thorax symmetrical, transverse diameter greater than AP diameter, deformity, breathing is regular and diaphragmatic, no use of accessory respiratory muscles, dilated veins, no scars, no retractions/bulging interspaces, symmetrical breathing pattern, masses, vesicular breath sounds on all lung fields, no adventitious sounds on all lung fields, bronchophony.
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HEART: Adynamic precordium, PMI located at 4 ICS, left MCL, no murmurs, no thrills. S1 best heard in the apex. S2 best heard in the base. ABDOMEN: Flat abdomen, no eversion of umbilicus, no bulging flanks, no visible pulsations, no rashes, no dilated veins, no striae, no scars, no masses. EXTREMITIES: No edema on both upper and lower extremities, no tenderness, no discolorations, no gross deformities. NEUROLOGIC EXAM Cerebral: Cannot be assessed. Cerebellar: No tremors. Cranial Nerves: I II III, IV, VI V VII VIII IX, X XI XII Not assessed. Not assessed. Not assessed. (+) Rooting Reflex. No facial and forehead asymmetry. Not assessed. Not assessed. Shoulders are symmetrical. Not assessed.
(+) Palmar Grasp Reflex (+) Plantar Grasp Reflex (+) Asymmetric Tonic Neck Reflex Other Reflexes were not assessed. VIII. Patient’s Salient Features 1. 2. 3. 4. 5. Bleeding umbilical stump Patient was born full term Patient is a neonate, 13 days old, male Patient is breastfed since birth Patient was not injected intramuscularly with Vitamin K at the time of birth
IX. Differential diagnoses Disease Hemorrhagic Disease of the Newborn resulting from deficiency in vitamin K Rule In A moderate decrease of factors II, VII, IX and X normally occurs in all newborn infants by 48-72 hours after birth, with a gradual return to birth levels by 7-10 days of age. Prolongation results to spontaneous and prolonged bleeding. Breast milk is a poor source of vitamin K, and hemorrhagic complications have appeared more commonly in breast-fed than formula-fed infants. The disease is characterized by bleeding that tends to be gastrointestinal, nasal, intracranial. Administering 1 mg of natural oil-soluble vitamin K intramuscularly at the time of birth prevents the fall in vitamin K-dependent factors in full-term infants. Rule Out
Hemophilia A is an X-linked recessive disorders; therefore, they affect males almost exclusively. Factor VIII does not cross the placenta, hence, bleeding tendency is evident in the neonatal period. Significant deficiency in FVIII or FIX may be evident in the neonatal period and continue through the life of the affected individual. At birth, neonates may present with prolonged bleeding from the cord or umbilical area.
In 80% of cases, family history is positive for the disease. Hematomas are common after injections or minor trauma. The hallmark of hemophilia is hemarthrosis.
Disseminated Intravascular Coagulation
The highest incidence of DIC is in the neonatal period. There may be bleeding in the umbilical stump.
More common in premature infants. DIC usually occurs in the context of respiratory distress syndrome and sepsis. Highly suspect presence of infection. The patient's general appearance frequently is toxic. The clinical picture is commonly one of bleeding with signs of shock out of proportion to the amount of blood loss, with poor perfusion, cold extremities, and poor tone in the neonate. Purpura fulminans (severe, extensive hemorrhage into the skin associated with fever and hypotension) caused by infections (especially
meningococcemia), protein C deficiency, or cutaneous purpuric or hemorrhagic lesions may develop and spread rapidly, which may progress to frank gangrene. DIC often is accompanied by renal, hepatic, pulmonary, or CNS manifestations; most patients are critically ill.
X. Diagnosis Hemorrhagic Disease of the Newborn resulting from vitamin K deficiency.
XI. Treatment Lab Studies: Include prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, and a platelet count in the initial workup for bleeding in a newborn. A thrombin clotting time (TCT) is optional. o A prolonged PT usually is the first laboratory test result to be abnormal in VKDB; however, no laboratory test can confirm the diagnosis of VKDB. Vitamin K direct assay is not useful because levels normally are low in newborns. Levels of protein induced by vitamin K antagonism (PIVKA) II are increased in VKDB, but this test generally is not available outside of research laboratories. Infants with VKDB typically have a prolonged PT with reference range platelet counts and fibrinogen levels. Thrombocytopenia or a prolonged aPTT should prompt workup for other causes of bleeding.
The diagnosis of VKDB is confirmed if administration of vitamin K brings a halt to the bleeding and reduces the PT value.
Intracranial bleeding is rare and usually associated with other causes of bleeding, particularly the thrombocytopenias; however, ICH has been reported in VKDB and can be fatal. Investigate any neurologic symptoms with a CT scan
Medical Care: Immediately administer a vitamin K SC dose for any infant in whom VKDB is suggested or with any sort of bleeding. o o IM administration can result in a hematoma because of the coagulopathy. IV administration of vitamin K has been associated with anaphylactoid reactions.
Fresh frozen plasma may be considered for moderate-to-severe bleeding. o o Life-threatening bleeding may also be treated with prothrombin complex concentrates (PCC). Because the bleeding in classic VKDB usually is not life threatening, a single dose of parenteral vitamin K is sufficient to stop the bleeding and return PT values to the reference range.
Administering 1 mg of natural oil-soluble vitamin K intramuscularly at the time of birth prevents the fall in vitamin K-dependent factors in full-term infants but is not uniformly effective in the prophylaxis of hemorrhagic disease of the newborn in premature infants. The disease may be effectively treated with an intravenous infusion of 1-5 mg of vitamin K1, with improvement of coagulation defects and cessation of bleeding within a few hours. However, serious bleeding, particularly in premature infants or those with liver disease, may require a transfusion of fresh frozen plasma or whole blood. The mortality rate is low among treated patients. A particularly severe form of deficiency of vitamin K-dependent coagulation factors has been reported in infants born to mothers receiving anticonvulsive medications during pregnancy. There may be severe bleeding with onset within the first 24 hours of life, which is usually corrected by vitamin K1, although in some, the response is poor or delayed. A prothrombin time (PT) should be obtained on cord blood and the infant given 1-2 mg of vitamin K intravenously. If the PT is greatly prolonged and fails to improve, 10 ml/kg of fresh frozen plasma should be given.