OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila
Name: CABALO, Baby girl Age/Sex: Newborn/F Address: 1913 G.F. Munoz St., Malate, Manila Date Admitted: 6/27/09 Admitting Diagnosis: Neonatal Pneumonia Residents-in-charge: Drs. Wingsing-Sucano/Ang/Arimao JIC: Galang/Gozun/Isanan/Jose/Libiran Patient Discharge Summary
Hospital No.: 650722
History of Present Illness: th This is a case of a newborn live baby girl full term to a 27 y/o G5P4 (4-0-0-4), 40 weeks AOG via NSD at OMMC. On the 6 hour of life, patient was seen with subcostal retractions and crackles, hence admission. Prenatal History: Patient’s mother had no prenatal check-up. She had CBC and urinalysis with unrecalled results. Mother had no intake of multivitamins or ferrous sulfate during her pregnancy. Mother denied any use of illicit drugs, teratogenic substances nor any exposure to radiation during her pregnancy. She also denies having hypertension, DM, thyroid problems, asthma and history of twinning. However, she claims to have had fever, st cough and colds on her 1 month of pregnancy with no intake of any medication. Birth History: Born full term to a27 y/o G5P5 (5-0-0-5) mother, 40 weeks AOG via NSD at OMMC. Obstetrical History: G5P4 (4-0-0-4) G1 2000 FT M Home, (-) FMC, 8lbs G2 2001 FT M Home, (-) FMC, 7lbs G3 2003 FT M OMMC, (-) FMC G4 2005 FT F Pedro Gil lying-in, (-) FMC, 6lbs G5 present pregmancy Physical examination: General: good activity, good cry and good tone Vital signs: HR:160bpm RR:54 T:37.3 Anthropometrics: BW: 2.55kg L: 49cm BS: 40 weeks AOG AS: 9,9 HC: 3.4cm CC: 32cm AC:31cm 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 girl born full term to a 27 y/o old G5P5(5-0-0-5), 40 weeks AOG via NSD at OMMC. Neonatal Pneumonia Plan: Patient was admitted at NICU under the services of Drs Nunez/Wingsing/Ang/Arimao. Patient was placed on NPO temporarily. IVF given was D10 water. Diagnostics requested were CBC w/ PC, CXR APL and blood CS. Therapeutics given were Ampicillin 65mg TIV every 6 hours
(100mkd) and Gentamicin 13mg IV given OD (5mkd). Oxygen support was given via hood at 8lpm. Hgt was monitored every 24hours while on NPO. The patient was observed for progression of respiratory distress. She was kept thermoregulated and vital signs were monitored every hour. Course in the wards: On first day of life, patient was seen comfortable, with good activity, no cyanosis but tachypneic and with minimal retractions. Hgt was 80mg/dl. Patient was slowly shifted from NPO to trial feeding. Oxygen support was maintained. IVF TF was D10 with Na, K and Ca. Medications were continued. She was ordered for blood C/S the next day. She was kept thermoregulated and suctioned for secretions as needed. On second day of life, phototherapy was started. 2cc/MF q3 was started w/ SAP. Oxygen support via funnel at 4-5lpm was given. HGT monitoring was done OD. Blood CS was facilitated. Medications were continued. IVF was continued. On same day, milk feeding was increased by 5cc q3 per cup every third feeding until 30cc q3 is reached. IVF was shifted to heplock once with full feeds. Oxygen support was continued. Blood C/S was facilitated. Patient was for repeat CBC w/ PC. rd On third day of life, 10cc MF/q3 was continued, it may be increased to 5cc q3 per cup every 3 feeding until 30cc/q3 is reached. IVF was shifted to heplock once with full feeds. Phototherapy, medications and IVF were continued. On fourth day of life, patient was placed on BF/MF with SAP. IVF was shifted to heplock. Medications were continued. Blood CS results were followed-up. NB care and cord care were continued. Warm compress alternating with cold compress was applied to affected area. On fifth day of life, patient was placed on MF/BF as tolerated with SAP. IV access was maintained. Medications were continued. Patient was exposed to phototherapy with proper shields. On sixth day of life, patient was placed on MF/BF as tolerated with SAP. IV access was maintained. Medications were continued. Phototherapy was discontinued. Present antibiotics were shifted to ceftazidime 85mg TIV q12(30mkd) and Oxacillin 140mg TIV q12(49mkd). NB care was continued. Patient was transferred to isolation room. On seventh day of life, patient was placed on MF as tolerated with SAP. Medications were continued. On eight day of life, patient was placed on MF as tolerated with SAP. Medications were continued. On ninth day of life, patient was placed on MF as tolerated with SAP. Medications were continued. On tenth day of life, patient was placed on MF as tolerated with SAP. Medications were continued. Bactoban was applied TID on previous IV sites. On eleventh day of life, patient was placed on MF as tolerated with SAP. Medications were continued. On twelfth day of life, patient was placed on MF as tolerated with SAP. Medications were continued. Patient was for repeat CBC with PC. Patient was kept thermoregulated. On thirteenth day of life, patient was placed on MF as tolerated with SAP. Medications were continued. Patient is for possible discharge tomorrow.