OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Caduyac, Baby boy Age/Sex: Newborn/M Address: 4-B Lailana St. Tondo, Manila Date Admitted: 7/20/09 Admitting Diagnosis: Neonatal pneumonia Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo Hospital No.: 651334
Clinical Abstract History of Present Illness: th This is a case of a newborn live baby boy born full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. On the 9 hour of life, patient was observed with a respiratory rate of 60 and a CXR AP/L result of pnuemonia, hence admission. Prenatal History: Patient’s mother had a total of 9 prenatal check-up, done at Ospital ng Tondo. The first prenatal check-up was at 5mos AOG and last check-up was at 9mos AOG. The mother had CBC, blood typing, UA, OCCP, UTZ and HBsAg done. Results of CBC and UA were normal. UTZ revealed uterine pregnancy and blood type was A. The patient’s mother had no maternal illness and took multivitamins and ferrous sulfate. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. The mother had UTI during pregnancy but no medications were taken. Birth History: Born full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. Obstetrical History: G4P3 (3-0-1-3) Physical examination: General: good activity, good cry and good tone Vital signs: HR:120sbpm RR:60 T:37.3 Anthropometrics: BW: 3.1kg L: 48cm BS: 39-40 weeks AOG AS: 9,9 HC: 35cm CC: 33cm AC: 28cm 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 full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. neonatal pneumonia
Plan: Patient was admitted to Pedia-NICU under the service of Drs Juico/Villa/Bonus/Ulob. Consent for admission was secured and patient was placed on NPO temporarily. Oxygen support via funnel at 5-6lpm was provided. IVF: D10W 186cc to run at 7-8ugtts/min (TFI=60cc/kg). Diagnostics requested were CBC with PC, CXR AP/L and blood C/S. Therapeutics were Ampicillin 155mg TIVq12 (100mkd) and Gentamicin 15mg TIV q24 (5mkd)once with UO. Patient was kept thermoregulated and HGT was done q24. VS was monitored q1.
OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Caduyac, Baby boy Age/Sex: Newborn/M Address: 4-B Lailana St. Tondo, Manila Date Admitted: 7/20/09 Admitting Diagnosis: Neonatal pneumonia Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo 24-Hour History History of Present Illness: th This is a case of a newborn live baby boy born full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. On the 9 hour of life, patient was observed with a respiratory rate of 60 and a CXR AP/L result of pnuemonia, hence admission. Prenatal History: Patient’s mother had a total of 9 prenatal check-up, done at Ospital ng Tondo. The first prenatal check-up was at 5mos AOG and last check-up was at 9mos AOG. The mother had CBC, blood typing, UA, OCCP, UTZ and HBsAg done. Results of CBC and UA were normal. UTZ revealed uterine pregnancy and blood type was A. The patient’s mother had no maternal illness and took multivitamins and ferrous sulfate. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. The mother had UTI during pregnancy but no medications were taken. Birth History: Born full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. Obstetrical History: G4P3 (3-0-1-3) Physical examination: General: good activity, good cry and good tone Vital signs: HR:120sbpm RR:60 T:37.3 Anthropometrics: BW: 3.1kg L: 48cm BS: 39-40 weeks AOG AS: 9,9 HC: 35cm CC: 33cm AC: 28cm 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 full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. neonatal pneumonia Hospital No.: 651334
Plan: Patient was admitted to Pedia-NICU under the service of Drs Juico/Villa/Bonus/Ulob. Consent for admission was secured and patient was placed on NPO temporarily. Oxygen support via funnel at 5-6lpm was provided. IVF: D10W 186cc to run at 7-8ugtts/min (TFI=60cc/kg). Diagnostics requested were CBC with PC, CXR AP/L and blood C/S. Therapeutics were Ampicillin 155mg TIVq12 (100mkd) and Gentamicin 15mg TIV q24 (5mkd)once with UO. Patient was kept thermoregulated and HGT was done q24. VS was monitored q1.
Course in the wards: st On first hospital day (1 day of life), patient was continued on MF with SAP. Oxygen support was discontinued. IVF was shifted to heplock. IV medications were continued, Ampicillin (D0 + 1) and Gentamicin (D0). Patient was still for blood C/S. D1-20L Patient was kept thermoregulated and VS were monitored q1. HR=140 RR=40 T=36.4 Hgt=60mg/dL Active, good suck/cry, no retractions, CBS, no sclerema, tolerates 30cc/MF
OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Caduyac, Baby boy Age/Sex: Newborn/M Address: 4-B Lailana St. Tondo, Manila Date Admitted: 7/20/09 Admitting Diagnosis: Neonatal pneumonia Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo Patient Discharge Summary History of Present Illness: th This is a case of a newborn live baby boy born full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. On the 9 hour of life, patient was observed with a respiratory rate of 60 and a CXR AP/L result of pnuemonia, hence admission. Prenatal History: Patient’s mother had a total of 9 prenatal check-up, done at Ospital ng Tondo. The first prenatal check-up was at 5mos AOG and last check-up was at 9mos AOG. The mother had CBC, blood typing, UA, OCCP, UTZ and HBsAg done. Results of CBC and UA were normal. UTZ revealed uterine pregnancy and blood type was A. The patient’s mother had no maternal illness and took multivitamins and ferrous sulfate. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. The mother had UTI during pregnancy but no medications were taken. Birth History: Born full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. Obstetrical History: G4P3 (3-0-1-3) Physical examination: General: good activity, good cry and good tone Vital signs: HR:120sbpm RR:60 T:37.3 Anthropometrics: BW: 3.1kg L: 48cm BS: 39-40 weeks AOG AS: 9,9 HC: 35cm CC: 33cm AC: 28cm 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 full term to a 25 y/o G4P3 (3-01-3), 39-40 weeks AOG via NSD at OMMC. neonatal pneumonia Hospital No.: 651334
Plan: Patient was admitted to Pedia-NICU under the service of Drs Juico/Villa/Bonus/Ulob. Consent for admission was secured and patient was placed on NPO temporarily. Oxygen support via funnel at 5-6lpm was provided. IVF: D10W 186cc to run at 7-8ugtts/min (TFI=60cc/kg). Diagnostics requested were CBC with PC, CXR AP/L and blood C/S. Therapeutics were Ampicillin 155mg TIVq12 (100mkd) and Gentamicin 15mg TIV q24 (5mkd)once with UO. Patient was kept thermoregulated and HGT was done q24. VS was monitored q1.
Course in the wards: st On first hospital day (1 day of life), patient was continued on MF with SAP. Oxygen support was discontinued. IVF was shifted to heplock. IV medications were continued, Ampicillin (D0 + 1) and Gentamicin (D0). Patient was still for blood C/S. D1-20L Patient was kept thermoregulated and VS were monitored q1. HR=140 RR=40 T=36.4 Hgt=60mg/dL Active, good suck/cry, no retractions, CBS, no sclerema, tolerates 30cc/MF On second hospital day (2 D20L HR=140 RR=42 T=37 Active, good suck/cry, no retractions, CBS, no sclerema Hgb=130 Hct=0.33 Nue=69 Mono=5.3 Eos=0.2 Lymp=25.4 WBC=11 PC=173
nd
day of life), MF with Sap was continued. Patient was maintained on heplock. Medications were continued. Patient was for blood C/S and CXR. Patient was kept thermoregulated. VS was monitored q1.