OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: AQUINO, BB. Girl Age/Sex: Newborn/F Address: Date Admitted: 7/21/09 Admitting Diagnosis: Meconium Aspiration Pneumonia Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Cantos/Castelo/Conde/Diaz/Evangelista Hospital No.: 651371
Clinical Abstract History of Present Illness: This is a case of a newborn live baby girl born full term to a 29 y/o G1P1 (1-0-0-1), 38-39 weeks AOG via NSD at OMMC. At birth, patient was thickly stained, no activity, bradycardic, limp, with stained umbilicus and was intubated at 1 minute. Hence, admission. Prenatal History: Patient’s mother had a total of 8 prenatal check-up, done at a health center. The first prenatal check up was at 2 months AOG and last prenatal check-up was at 9 months AOG. The mother had CBC, BT (type B), UA and UTZ done. Patient’s mother took multivitamins and ferrous sulfate. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. Patient’s mother has no comorbidities as well. Birth History: Born full term to a 29 y/o G1P1 (1-0-0-1), 38-39 weeks AOG via NSD at OMMC. Obstetrical History: G1P1 (1-0-0-1) Physical examination: General: thickly stained, no activity, bradycardic, limp, stained umbilicus and was intubated at 1 minute. Anthropometrics: BW: 2.55 kg BS: 38-39 weeks AOG AS: 4,6,6 HC: 35 cm CC: 36 cm AC: 31 cm Skin: good skin turgor, (-) rashes, (-) hematoma, (-) desquamation Head: (-)caput, (-)molding, (-)craniotables, (-) cephalhematoma Face: (-) asymmetry ENT: (-) conjunctivitis, (-) discharge, (+) patent nose, (-) cleft lip, (-) cleft palate Chest and Lungs: (+) breast bud, (-) clavicular fracture, (+) NRRR, (+) subcostal retractions, clear breath sounds Abdomen: flat, (-) masses Extremities: (-)cyanosis, (-)edema, (-)club foot, (+)full and equal pulses Reflexes: (+) moro, (+) sucking. (+) grasping Assessment: Live baby girl born full term to a 29 y/o G1P1 (1-0-0-1), 38-39 weeks AOG via LTCS x NSD at OMMC. Meconium Aspiration Pneumonia Plan: Patient was admitted to Pedia-NICU under the service of Drs Juico/Villa/Bonus/Ulob. Consent for admission was secured. Patient was intubated with ET 3.5 level 10-11 and was on continuous ambubagging. Patient was placed on NPO temporarily. D10W 170 cc x 24 hours to run at 7-8ugtts/min. Diagnostics requested were CBC with PC, CXR-APL after 6 hour of life, blood CS and ABG’s. Medications given were Ampicillin and Gentamicin. Watch out for progression of respiratory distress. Patient was kept thermoregulated. Vital signs were monitored every hour.
OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: AQUINO, BB. Girl Age/Sex: Newborn/F Address: Date Admitted: 7/21/09 Admitting Diagnosis: Meconium Aspiration Pneumonia Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Cantos/Castelo/Conde/Diaz/Evangelista Hospital No.: 651371
PATIENT DISCHARGE SUMMARY History of Present Illness: This is a case of a newborn live baby girl born full term to a 29 y/o G1P1 (1-0-0-1), 38-39 weeks AOG via NSD at OMMC. At birth, patient was thickly stained, no activity, bradycardic, limp, with stained umbilicus and was intubated at 1 minute. Hence, admission. Prenatal History: Patient’s mother had a total of 8 prenatal check-up, done at a health center. The first prenatal check up was at 2 months AOG and last prenatal check-up was at 9 months AOG. The mother had CBC, BT (type B), UA and UTZ done. Patient’s mother took multivitamins and ferrous sulfate. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. Patient’s mother has no comorbidities as well. Birth History: Born full term to a 29 y/o G1P1 (1-0-0-1), 38-39 weeks AOG via NSD at OMMC. Obstetrical History: G1P1 (1-0-0-1) Physical examination: General: thickly stained, no activity, bradycardic, limp, stained umbilicus and was intubated at 1 minute. Anthropometrics: BW: 2.55 kg BS: 38-39 weeks AOG AS: 4,6,6 HC: 35 cm CC: 36 cm AC: 31 cm Skin: good skin turgor, (-) rashes, (-) hematoma, (-) desquamation Head: (-)caput, (-)molding, (-)craniotables, (-) cephalhematoma Face: (-) asymmetry ENT: (-) conjunctivitis, (-) discharge, (+) patent nose, (-) cleft lip, (-) cleft palate Chest and Lungs: (+) breast bud, (-) clavicular fracture, (+) NRRR, (+) subcostal retractions, clear breath sounds Abdomen: flat, (-) masses Extremities: (-)cyanosis, (-)edema, (-)club foot, (+)full and equal pulses Reflexes: (+) moro, (+) sucking. (+) grasping Assessment: Live baby girl born full term to a 29 y/o G1P1 (1-0-0-1), 38-39 weeks AOG via LTCS x NSD at OMMC. Meconium Aspiration Pneumonia Plan: Patient was admitted to Pedia-NICU under the service of Drs Juico/Villa/Bonus/Ulob. Consent for admission was secured. Patient was intubated with ET 3.5 level 10-11 and was on continuous ambubagging. Patient was placed on NPO temporarily. D10W 170 cc x 24 hours to run at 7-8ugtts/min. Diagnostics requested were CBC with PC, CXR-APL after 6 hour of life, blood CS and ABG’s. Medications given were Ampicillin and Gentamicin. Watch out for progression of respiratory distress. Patient was kept thermoregulated. Vital signs were monitored every hour. Course in the Wards: From 1st hospital day to 10th hospital day, patient was placed on NPO temporarily and was then shifted to MF with SAP. Previously ordered medications were continued as well as IVF. Blood CS was requested and showed Burkholderia cepacia. Hence, patient was then started on Ciprofloxacin. After completing the course of Ciprofloxacin CBC with PC was repeated and showed normal results. After which, patient was then allowed to go home on the 10th hospital day. Take home medication given was Ciprofloxacin for 4 more days. Patient was scheduled for follow-up on August 5, 2009 at Pedia-OPD.