BESA

OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Besa, Baby boy Age/Sex: Newborn/M Address: Bgy. 649Z-68 Baseco Port area, Mla Date Admitted: 7/10/09 Admitting Diagnosis: Neonatal pneumonia Residents-in-charge: Drs. Juico/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo Clinical Abstract Hospital No.: 650941 History of Present Illness: This is a case of a newborn live baby boy born full term to a 16 y/o G1P1 (1-0-0-1), 39-40 weeks AOG via th NSD at OMMC. On the 8 hour of life, patient was observed with poor feeding and minimal subcostal retractions, hence admission. Prenatal History: Patient’s mother had a total of 5 prenatal check-up, done at Baseco health center. The first prenatal checkup was at 5mos AOG and last check-up was at 8mos AOG. The mother had CBC, blood typing, UA, UTZ and HBsAg done. The patient’s mother had no maternal illness and co-morbidities. The mother took multivitamins and ferrous sulfate and had no history of use of illicit drugs, teratogenic substances and exposure of radiation. Birth History: Born full term to a 16 y/o G1P0 (1-0-0-0) mother, 39-40 weeks AOG via NSD at OMMC. Obstetrical History: G1P0 (1-0-0-0) Physical examination: General: good activity, good cry and good tone Vital signs: HR:160bpm RR:60 T:37.3 Anthropometrics: BW: 3.15kg L: 53cm BS: 39-40 weeks AOG AS: 4,5,8 HC: 33cm CC: 32cm AC: 29cm 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 Extremeties: (-)cyanosis, (-)edema, (-)polydactylism, (-)syndactylism, (-)club foot, (+)full and equal pulses Reflexes: (+) moro, (+) sucking. (+) grasping Assessment: Live baby boy born pre term to a 16 y/o old G1P1(1-0-0-1), 39-40 weeks AOG via NSD at OMMC. T/C neonatal pneumonia R/O sepsis neonatorium Plan: Patient was admitted to NICU under the service of Drs Juico/Bonus/Ulob. Consent for admission and management was secured. Patient was placed on NPO-TFO. Hgt was done. IVF (TFI 60cc/kg) D10W 189cc x 24h to run at 7-8ugtts/min. Diagnostics requested were CBC with PC, chest AP/L and blood CS. Medications prescribed were Ampicillin 160mg TIV q12 (100mkd), Gentamycin 15mg TIV q24(5mkd) w/ UO. Patient was kept thermoregulated. VS was monitored every hour. OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Besa, Baby boy Age/Sex: Newborn/M Address: Bgy. 649Z-68 Baseco Port area, Mla Date Admitted: 7/10/09 Admitting Diagnosis: Neonatal pneumonia Residents-in-charge: Drs. Juico/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo 24-Hour History Hospital No.: 650941 History of Present Illness: This is a case of a newborn live baby boy born full term to a 16 y/o G1P1 (1-0-0-1), 39-40 weeks AOG via th NSD at OMMC. On the 8 hour of life, patient was observed with poor feeding and minimal subcostacal retractions, hence admission. Prenatal History: Patient’s mother had a total of 5 prenatal check-up, done at Baseco health center. The first prenatal checkup was at 5mos AOG and last check-up was at 8mos AOG. The mother had CBC, blood typing, UA, UTZ and HBsAg done. The patient’s mother had no maternal illness and co-morbidities. The mother took multivitamins and ferrous sulfate and had no history of use of illicit drugs, teratogenic substances and exposure of radiation. Birth History: Born full term to a 16 y/o G1P0 (1-0-0-0) mother, 39-40 weeks AOG via NSD at OMMC. Obstetrical History: G1P0 (1-0-0-0) Physical examination: General: good activity, good cry and good tone Vital signs: HR:160bpm RR:60 T:37.3 Anthropometrics: BW: 3.15kg L: 53cm BS: 39-40 weeks AOG AS: 4,5,8 HC: 33cm CC: 32cm AC: 29cm 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 Extremeties: (-)cyanosis, (-)edema, (-)polydactylism, (-)syndactylism, (-)club foot, (+)full and equal pulses Reflexes: (+) moro, (+) sucking. (+) grasping Assessment: Live baby boy born pre term to a 16 y/o old G1P1(1-0-0-1), 39-40 weeks AOG via NSD at OMMC. T/C neonatal pneumonia R/O sepsis neonatorium Plan: Patient was admitted to NICU under the service of Drs Juico/Bonus/Ulob. Consent for admission and management was secured. Patient was placed on NPO-TFO. Hgt was done. IVF (TFI 60cc/kg) D10W 189cc x 24h to run at 7-8ugtts/min. Diagnostics requested were CBC with PC, chest AP/L and blood CS. Medications prescribed were Ampicillin 160mg TIV q12 (100mkd), Gentamycin 15mg TIV q24(5mkd) w/ UO. Patient was kept thermoregulated. VS was monitored every hour. Course in the wards: CR: 149 RR: 62 T: 36.9 Active, good cry, (+) min retractions, soft abd, full pulses, tolerates 5cc, (+)BM nd On first hospital day (2 day of life), MF with SAP (5cc q3) was done. IVF and IV medications were continued. VS was monitored every hour. On same hospital day, IVF TFO was D10W 220cc x 24h at a rate of 9-10ugtts/min (70cc/kg). OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Besa, Baby boy Age/Sex: Newborn/M Address: Bgy. 649Z-68 Baseco Port area, Mla Date Admitted: 7/10/09 Admitting Diagnosis: Neonatal pneumonia Residents-in-charge: Drs. Juico/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo Patient Discharge Summary Hospital No.: 650941 History of Present Illness: This is a case of a newborn live baby boy born full term to a 16 y/o G1P1 (1-0-0-1), 39-40 weeks AOG via th NSD at OMMC. On the 4 day of life, patient was observed with increased sleeping time, hence admission. Prenatal History: Patient’s mother had a total of 5 prenatal check-up, done at Baseco health center. The first prenatal checkup was at 5mos AOG and last check-up was at 8mos AOG. The mother had CBC, blood typing, UA, UTZ and HBsAg done. The patient’s mother had no maternal illness and co-morbidities. The mother took multivitamins and ferrous sulfate and had no history of use of illicit drugs, teratogenic substances and exposure of radiation. Birth History: Born full term to a 16 y/o G1P0 (1-0-0-0) mother, 39-40 weeks AOG via NSD at OMMC. Obstetrical History: G1P0 (1-0-0-0) Physical examination: General: good activity, good cry and good tone Vital signs: HR:160bpm RR:60 T:37.3 Anthropometrics: BW: 3.15kg L: 53cm BS: 39-40 weeks AOG AS: 4,5,8 HC: 33cm CC: 32cm AC: 29cm 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 Extremeties: (-)cyanosis, (-)edema, (-)polydactylism, (-)syndactylism, (-)club foot, (+)full and equal pulses Reflexes: (+) moro, (+) sucking. (+) grasping Assessment: Live baby boy born pre term to a 16 y/o old G1P1(1-0-0-1), 39-40 weeks AOG via NSD at OMMC. T/C neonatal pneumonia R/O sepsis neonatorium Plan: Patient was admitted to NICU under the service of Drs Juico/Bonus/Ulob. Consent for admission and management was secured. Patient was placed on NPO-TFO. Hgt was done. IVF (TFI 60cc/kg) D10W 189cc x 24h to run at 7-8ugtts/min. Diagnostics requested were CBC with PC, chest AP/L and blood CS. Medications prescribed were Ampicillin 160mg TIV q12 (100mkd), Gentamycin 15mg TIV q24(5mkd) w/ UO. Patient was kept thermoregulated. VS was monitored every hour. Course in the wards: nd On first hospital day (2 day of life), MF with SAP (5cc q3) was done. IVF and IV medications were continued. VS was monitored every hour. CR: 149 RR: 62 On same hospital day, IVF TFO was D10W 220cc x 24h at a T: 36.9 rate of 9-10ugtts/min (70cc/kg). Active, good cry, (+) min retractions, soft abd, full pulses, tolerates 5cc, (+)BM rd On second hospital day (3 day of life), MF was increased as tolerated with SAP. IVF was shifted to heplock once 30cc q3 is tolerated. Oxygen support was discontinued. Medications were CR: 140 RR: 50 continued. Blood CS were facilitate. Routine NB care was given. Patient was T: 37.2 O2 sat: 95 exposed to phototherapy with proper eye shield. IVF D10W 95ml to run at Jaundice 4ugtts/min (TFI 80cc/kg) 25cc q3 tolerated 54.9 167 12.2 7 197 31.6 148 1.3 D2-30L Comfortable, good activity, SCE, no retractions, CBS On third hospital day (4 day of life), IVF was discontinued and shifted to heplock. Feeding intolerance was watched out for. IV medications were continued. Patient was for CR: 150 RR: 50 phototherapy with eye shields. Patient was still for blood c/s. T: 37.1 Jaundice, 30cc q3 tolerated, D3-40L No vomiting, soft abdomen, CBS, (+)BM, (+)UO. th On the fourth hospital day (5 day of life), patient was able to tolerate 20ml of MF and was given IVF to ff D10W 95ml to run at 4ugtts/min(TFI 80cc/kg). On same hospital day, IVF was discontinued and was CR: 150 RR: 50 T: 37.1 shifted to heplock. Ampicillin and Gentamicin were continued. Active, Tolerates 30ml q3 Patient was for phototherapy with eye shield. Diagnostic (-) vomiting, soft abdomen, CBS, (+)BM, (+)UO requested were blood c/s. On fifth hospital day (6 day of life), patient was maintained on heplock. Ampicillin and Gentamicin were continued. Patient was for repeat CBC with PC. Rebound jaundice, CR: 160 RR: 50 T: 36.3 Hgt: 80 retractions and cyanosis were watched-out for. VS was monitored Active, comfortable, (-) jaundice q1. (-) vomiting, soft abdomen, CBS, full pulses CXR-APL: pneumonia, right th th th On sixth hospital day (7 day of life), patient was placed on MF/BF as tolerated with SAP. IV access was maintained. Ampicillin and gentamicin were continued. CR: 150 RR: 50 T: 36.5 Phototherapy was discontinued. Patient was kept Active, good suck, (-) jaundice, soft abdomen, CBS thermoregulated. On seventh hospital day (8 day of life), patient was placed on MF with SAP and maintained on heplock. Medications were continued and patient was kept CR: 152 RR: 50 T: 36.5 thermoregulated. Active, good suck, (-) jaundice, soft abdomen, CBS th On eight hospital day (ninth day of life), patient was still on MF with SAP. Medications were continued (Ampcillin D7, Gentamicin D8). Patient was for repeat CBC and is for CR: 150 RR: 50 T: 36.5 possible discharge once with CBC and blood C/C results. Patient was kept Active, good suck, (-) retractions, thermoregulated. CBS, full pulses On ninth hospital day (tenth day of life), patient was allowed to go home with mother. Patient was for follow-up at OPD on July 24, 2009 (Friday, well baby clinic). NB and cord care CR: 142 RR: 52 were advised to be continued. Patient was on BF as tolerated with SAP. T: 36.5 Clinically well Blood c/s: no growth Hgb: 165 Hct: 47 Neu: 69 Mono: 6.4 Eosino: Lympho: 24.6 WBC: 9 PC: 155 Ampi: D8 Genta: D9