Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila
Patient’s Name: LIBAY III, Baby Girl Address: 2548 Celeridad Street, Pasay City Age/Sex: NB/F Date Admitted: June 20, 2008 Admitting Diagnosis: Prematurity R/O Sepsis Physician–in-charge: Dr.Nunez/Villa/Manalo Clerk-in-charge: Florentino/Kalalo/Lingao/Liwag/Lopez
Hospital No. 640746
CLINICAL ABSTRACT This is a case of a live baby girl born preterm to a G3 P3 (2-4-0-6) mother via NSD. PAST MEDICAL HISTORY Pre-natal: Mother did not have her pre-natal check-up. She denies having any illnesses during her pregnancy. st Birth: Patient was born preterm via LTCS secondary to multiple pregnancies. APGAR at the 1 minute was 9, at 5 minutes was 9. Ballard score was 35-36 weeks. Birth weight was 1.8 kg, birth length was 43 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: 0 HR = 140 bpm RR = 60 cpm Temp = 36.5 C Anthropometrics: Weight = 1.8 kg Length = 43 cm Head circumference = 30 cm Chest circumference = 26 cm Abdominal circumference = 24 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: Prematurity R/O Sepsis PLAN: For admission
Patient was admitted to the NICU under the service of Drs. Nunez/Villa/Manalo. Umbicath was inserted. Patient was placed on NPO. IVF: D10W 144 mL x 24 hours at a rate of 6 ugtts/min. O2 support was given via hood at 6-8 lpm. Patient was placed in incubation and thermoregulated aggressively. Laboratories requested were CBC with PC, blood typing, CXR-AP/L and blood CS. Therapeutics: piperacillin tazobactam 90 mg q 12 hours, gentamycin 9 mg SIVP q 36 hours and ranitidine 1.5 mg TIV q 8 hours while on NPO. Input and output were monitored every 8 hours. Vital signs were monitored every hour.