Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila CLINICAL ABSTRACT
Patient’s Name: Abapo, Baby Boy Hospital No. 651136 Address: San Andres, Manila Age/Sex: NB/M Date admitted:7/13/09 Admitting diagnosis: Live Baby boy born full term to a 20 yo G1P1 1-0-0-1 mother 39-40 weeks AOG via NSD on breech presentation
This is a case of a live baby boy born full term to a 20y/o G1P1 (1-0-0-1) via NSD on Breech Presentation with an APGAR score of 3,7 and is 39-34 weeks AOG by Ballards Scoring. Prenatal history Patient’s mother had 1 prenatal checkup at Jose Reyes Hospital where CBC, UA, HbsAg, were done which revealed normal results. Mother noted to have no illness during time of pregnancy. Mother noted intake of multivitamins. She denies intake of alcohol and illegal drugs. Mother denies any cormorbid diseases. OBSTETRICS HISTORY G1P0 (1-0-0-0) PHYSICAL EXAMINATION GENERAL SURVEY: fair activity, good cry, good tone, (-) cardio respiratory distress. SKIN: pale color, good skin turgor. VS: hr= 162 rr= 69 temp= 36.2 HEAD: (-)caput, (-)molding, (-)craniotabes, (-)cephalhematoma. FACE: (-)asymmetry EYES: (-)conjunctivitis, (-)discharge ENT: (+)patent nose, (-)cleft lip, (-)cleft palate CHEST: (+)breast bud, (-)clavicular fracture, (+)NRRR, (+)CBS ABDOMEN: (+)globular, (-)mass GENITALS: unre,arkable Trunk and Spine: (-)spina bifida, (-)deformity EXTREMITY: (+) fracture, middle third, arm right, (-)cyanosis, (-)edema, (-)polydactylism, (-)syndactylism, (-)club foot, (+)full equal pulses. ANTHROPOMETRICS: BL 46 cm BW 2.6 kg HC 33 cm CC 28 cm AC 28 cm ASSESSMENT: Live Baby boy born full term to a 20 yo G1P1 1-0-0-1 mother 39-40 weeks AOG via NSD on breech presentation. PLAN For admission
Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila 24-Hour History
Patient’s Name: Abapo, Baby Boy Hospital No. 651136 Address: San Andres, Manila Age/Sex: NB/M Date admitted:7/13/09 Admitting diagnosis: Live Baby boy born full term to a 20 yo G1P1 1-0-0-1 mother 39-40 weeks AOG via NSD on breech presentation
This is a case of a live baby boy born full term to a 20y/o G1P1 (1-0-0-1) via NSD on Breech Presentation with an APGAR score of 3,7 and is 39-34 weeks AOG by Ballards Scoring. Prenatal history Patient’s mother had 1 prenatal checkup at Jose Reyes Hospital where CBC, UA, HbsAg, were done which revealed normal results. Mother noted to have no illness during time of pregnancy. Mother noted intake of multivitamins. She denies intake of alcohol and illegal drugs. Mother denies any cormorbid diseases. OBSTETRICS HISTORY G1P0 (1-0-0-0) PHYSICAL EXAMINATION GENERAL SURVEY: fair activity, good cry, good tone, (-) cardio respiratory distress. SKIN: pale color, good skin turgor. VS: hr= 162 rr= 69 temp= 36.2 HEAD: (-)caput, (-)molding, (-)craniotabes, (-)cephalhematoma. FACE: (-)asymmetry EYES: (-)conjunctivitis, (-)discharge ENT: (+)patent nose, (-)cleft lip, (-)cleft palate CHEST: (+)breast bud, (-)clavicular fracture, (+)NRRR, (+)CBS ABDOMEN: (+)globular, (-)mass GENITALS: unre,arkable Trunk and Spine: (-)spina bifida, (-)deformity EXTREMITY: (+) fracture, middle third, arm right, (-)cyanosis, (-)edema, (-)polydactylism, (-)syndactylism, (-)club foot, (+)full equal pulses. ANTHROPOMETRICS: BL 46 cm BW 2.6 kg HC 33 cm CC 28 cm AC 28 cm ASSESSMENT: Live Baby boy born full term to a 20 yo G1P1 1-0-0-1 mother 39-40 weeks AOG via NSD on breech presentation. PLAN For admissiondone Course in the Wards: At birth, patient was active, with minimal SC retractions, harsh breath sounds, good suck, no vomiting. On the 1st day, patient was given O2 support at 8L/min via hood. At 8HOL, patient was tachypneic which was persistent. DDX was Neonatal Pneumonia. Patient was hooked to D10W 174.2 mL with additives to run at 7-8 microdrops/min. Meds were: Ampicillin 130 mg TIV q12 and Gentamicin 13 mg TIV q24. On the 2nd day, Vitals were within normal limits. Patient was active, with good cry and was noted to have fracture in the arm, right. Shoulder and arm APL Xrays confirmed a complete transverse fracture on the middle third of humerus, right. IVF and IV meds were continued. He was referred to Surgery for further evaluation and management of fractured limb.
Ospital ng Maynila Medical Center DEPARTMENT OF PEDIATRICS Quirino Avenue corner Roxas Boulevard Malate, Manila Patient Discharge Summary
Patient’s Name: Abapo, Baby Boy Hospital No. 651136 Address: San Andres, Manila Age/Sex: NB/M Date admitted:7/13/09 Admitting diagnosis: Live Baby boy born full term to a 20 yo G1P1 1-0-0-1 mother 39-40 weeks AOG via NSD on breech presentation
This is a case of a live baby boy born full term to a 20y/o G1P1 (1-0-0-1) via NSD on Breech Presentation with an APGAR score of 3,7 and is 39-34 weeks AOG by Ballards Scoring. Prenatal history Patient’s mother had 1 prenatal checkup at Jose Reyes Hospital where CBC, UA, HbsAg, were done which revealed normal results. Mother noted to have no illness during time of pregnancy. Mother noted intake of multivitamins. She denies intake of alcohol and illegal drugs. Mother denies any cormorbid diseases. OBSTETRICS HISTORY G1P0 (1-0-0-0) PHYSICAL EXAMINATION GENERAL SURVEY: fair activity, good cry, good tone, (-) cardio respiratory distress. SKIN: pale color, good skin turgor. VS: hr= 162 rr= 69 temp= 36.2 HEAD: (-)caput, (-)molding, (-)craniotabes, (-)cephalhematoma. FACE: (-)asymmetry EYES: (-)conjunctivitis, (-)discharge ENT: (+)patent nose, (-)cleft lip, (-)cleft palate CHEST: (+)breast bud, (-)clavicular fracture, (+)NRRR, (+)CBS ABDOMEN: (+)globular, (-)mass GENITALS: unre,arkable Trunk and Spine: (-)spina bifida, (-)deformity EXTREMITY: (+) fracture, middle third, arm right, (-)cyanosis, (-)edema, (-)polydactylism, (-)syndactylism, (-)club foot, (+)full equal pulses. ANTHROPOMETRICS: BL 46 cm BW 2.6 kg HC 33 cm CC 28 cm AC 28 cm ASSESSMENT: Live Baby boy born full term to a 20 yo G1P1 1-0-0-1 mother 39-40 weeks AOG via NSD on breech presentation. PLAN For admissiondone Course in the Wards: At birth, patient was active, with minimal SC retractions, harsh breath sounds, good suck, no vomiting. On the 1st day, patient was given O2 support at 8L/min via hood. At 8HOL, patient was tachypneic which was persistent. DDX was Neonatal Pneumonia. Patient was hooked to D10W 174.2 mL with additives to run at 7-8 microdrops/min. Meds were: Ampicillin 130 mg TIV q12 and Gentamicin 13 mg TIV q24. On the 2nd and 3rd day, Vitals were within normal limits. Patient was active, with good cry and was noted to have fracture in the arm, right. Shoulder and arm APL Xrays confirmed a complete transverse fracture on the middle third of humerus, right. IVF and IV meds were continued. He was referred to Surgery for further evaluation and management of fractured limb. The Dept. of Surgery opted to discuss the case with the consultants. On the 4th day, Patient has good activity, minimal retractions, clear breath sounds, full pulses . Vitals were within normal limits. O2 support was continued. IVF and IV meds were continued. Blood C/S wasrequested. Hgt monitoring q24 was continued. Pelvic APL
revealed chip fracture at the proximal femur, left. Skull APL showed a small bony density seen in the inferior portion of the mandible near the angle. On the 5th day, patient has good activity, clear breath sounds with clear OGT output. Vitals are within normal limits. IVF and IV meds were continued. Patient was referred back to Dept. of Surgery. On the 6th day, patient was noted to have sallow skin, fair to good activity, subcostal retractions, clear breath sounds, soft abdomen, no murmurs and with edema of both legs. Patient was seen and examined by neuropedia. Suggested plan was EMG. O2 support was continued. IVF and IV meds were continued but there is an option to shift to Cefta-Oxa-Amik (COA) once available. Patient was under close watch. On the 7th day, patient has fair activity, symmetrical chest expansion, minimal subcostal retractions, clear breath sounds, soft abdomen, edema of scrotal area, full pulses and bilateral edema of legs. Vitals are within normal limits. COA was still not available. Piptazo 260 mg TIV q 12 and Amikacin may be given. O2 support was continued. CBC showed platelet of 153. FFP was then requested to be transfused. On the 8th day, patient had eye discharge, both eyes and an IV burn over the right foot, dorsum. Still with minimal subcostal retractions, clear breath sounds, soft abdomen, edema of scrotal area, full pulses and bilateral edema of legs. Vitals are within normal limits. O2 support was continued. IVF and IV meds were continued. Silver Sulfadiazine cream was applied on the burn area. Erythromycin E/S was also prescribed. Patient was again referred back to Dept of Surgery which advised transfer of patient to PGHDept of orthopedics for appropriate management. On the 9th day, patient still had eye discharge, leg edema, scrotal edema and minimal retractions. IVF and IV meds was still continued. Patient’s parents agreed to transfer to PGH.