EVangelista

OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Evangelista, Baby boy Age/Sex: Newborn/M Address: 2285 P. Rizal St. Makati City Date Admitted: 7/6/09 Admitting Diagnosis: Sepsis neonatorium Prematurity Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo Clinical Abstract Hospital No.: 650941 History of Present Illness: th This is a case of a newborn live baby boy born pre term to a 17 y/o G1P1 (0-1-0-1), 34 weeks AOG via 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 3 prenatal check-up, done at Sta. Ana health center. The first prenatal check-up was at 6mos AOG and last check-up was at 7mos AOG. The mother had no CBC, blood typing, UA, OCCP and HBsAg done but had ultrasound and results revealed a intrauterine pregnancy of a 6mos old baby boy. 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 pre term to a 17 y/o G1P1 (0-1-0-1) mother, 34 weeks AOG via NSD at OMMC. Obstetrical History: G1P0 (0-1-0-0) Physical examination: General: good activity, good cry and good tone Vital signs: HR:150bpm RR:58 T:37.3 Anthropometrics: BW: 1.7kg L: 42cm BS: 34 weeks AOG AS: 9,9 HC: 29cm CC: 25cm AC: 25cm 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 17 y/o old G1P1(0-1-0-1), 34 weeks AOG via NSD at OMMC. Sepsis neonatorum Prematurity Plan: Patient was admitted to NICU under the service of Drs Juico/Villa/Bonus/Ulob. Consent for admission and management was secured. Milk feeding was done 5ml every 3hours. IVF (TFI 110cc/kg) D10W 142.9ml, (3) Na 2ml, (2) K 1.7ml, (200) Ca 3.4ml, a total of 150ml to run at 6-7 ugtss/min. Diagnostics requested were CBC with PC, skull AP/L/CXR, cranial CT scan and blood CS. Medications prescribed were Ampicillin 90mg TIV q12 (106mkd), Gentamycin 8mg TIV q24(5mkd) and erythromycin E/S TID. HGT was monitored every 24h. Patient was kept thermoregulated. Routine NB care was given. OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Evangelista, Baby boy Age/Sex: Newborn/M Address: 2285 P. Rizal St. Makati City Date Admitted: 7/6/09 Admitting Diagnosis: Sepsis neonatorium Prematurity Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo 24-hour History Hospital No.: 650941 History of Present Illness: th This is a case of a newborn live baby boy born pre term to a 17 y/o G1P1 (0-1-0-1), 34 weeks AOG via 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 3 prenatal check-up, done at Sta. Ana health center. The first prenatal check-up was at 6mos AOG and last check-up was at 7mos AOG. The mother had no CBC, blood typing, UA, OCCP and HBsAg done but had ultrasound and results revealed a intrauterine pregnancy of a 6mos old baby boy. 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 pre term to a 17 y/o G1P1 (0-1-0-1) mother, 34 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:150bpm RR:58 T:37.3 Anthropometrics: BW: 1.7kg L: 42cm BS: 34 weeks AOG AS: 9,9 HC: 29cm CC: 25cm AC: 25cm 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 17 y/o old G1P1(1-0-0-1), 34 weeks AOG via NSD at OMMC. Sepsis neonatorum Prematurity Plan: Patient was admitted to NICU under the service of Drs Juico/Villa/Bonus/Ulob. Consent for admission and management was secured. Milk feeding was done 5ml every 3hours. IVF (TFI 110cc/kg) D10W 142.9ml, (3) Na 2ml, (2) K 1.7ml, (200) Ca 3.4ml, a total of 150ml to run at 6-7 ugtss/min. Diagnostics requested were CBC with PC, skull AP/L/CXR, cranial CT scan and blood CS. Medications prescribed were Ampicillin 90mg TIV q12 (106mkd), Gentamycin 8mg TIV q24(5mkd) and erythromycin E/S TID. HGT was monitored every 24h. Patient was kept thermoregulated. Routine NB care was given. Course in the wards: D50L Fair activity, fair suck, tolerates 5ml, (+)apneic episodes, soft fontanel, SCE, no retractions, CBS, AP, NCRRR, no murmurs, flat, NABS, soft, full pulses, Hgt=120mg/dL On first hospital day (4 day of life), MF was increased to 10ml q3 if tolerated. Oxygen support via funnel at 45lpm was given. IVF (TFI 120cc/kg – MF) (D10W 196cc, Na (3) 2cc, K (2) 1.7cc, Ca (200) 3.4cc) 204cc to run at 89cc/hour. Previously ordered medications were continued. Losses were monitored and replaced with PNSS vol/vol. Aminophylline 14mg was given immediately then 5mg TIV q12(LD=8, MD=3) th OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Evangelista, Baby boy Age/Sex: Newborn/M Address: 2285 P. Rizal St. Makati City Date Admitted: 7/6/09 Admitting Diagnosis: Sepsis neonatorium Prematurity Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo Patient Discharge Summary Hospital No.: 650941 History of Present Illness: th This is a case of a newborn live baby boy born pre term to a 17 y/o G1P1 (0-1-0-1), 34 weeks AOG via 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 3 prenatal check-up, done at Sta. Ana health center. The first prenatal check-up was at 6mos AOG and last check-up was at 7mos AOG. The mother had no CBC, blood typing, UA, OCCP and HBsAg done but had ultrasound and results revealed a intrauterine pregnancy of a 6mos old baby boy. 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 pre term to a 17 y/o G1P1 (0-1-0-1) mother, 34 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:150bpm RR:58 T:37.3 Anthropometrics: BW: 1.7kg L: 42cm BS: 34 weeks AOG AS: 9,9 HC: 29cm CC: 25cm AC: 25cm 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 17 y/o old G1P1(1-0-0-1), 34 weeks AOG via NSD at OMMC. Sepsis neonatorum Prematurity Plan: Patient was admitted to NICU under the service of Drs Juico/Villa/Bonus/Ulob. Consent for admission and management was secured. Milk feeding was done 5ml every 3hours. IVF (TFI 110cc/kg) D10W 142.9ml, (3) Na 2ml, (2) K 1.7ml, (200) Ca 3.4ml, a total of 150ml to run at 6-7 ugtss/min. Diagnostics requested were CBC with PC, skull AP/L/CXR, cranial CT scan and blood CS. Medications prescribed were Ampicillin 90mg TIV q12 (106mkd), Gentamycin 8mg TIV q24(5mkd) and erythromycin E/S TID. HGT was monitored every 24h. Patient was kept thermoregulated. Routine NB care was given. Course in the wards: th On first hospital day (4 day of life), MF was increased to 10ml q3 if tolerated. Oxygen support via funnel at 4-5lpm was given. IVF (TFI 120cc/kg – MF) (D10W 196cc, Na (3) 2cc, K (2) 1.7cc, Ca (200) 3.4cc) 204cc to run at 8-9cc/hour. Previously ordered medications were continued. Losses were monitored and replaced with PNSS vol/vol. Aminophylline 14mg was given D50L Fair activity, fair suck, immediately then 5mg TIV q12(LD=8, MD=3) tolerates 5ml, (+)apneic episodes, soft fontanel, SCE, no retractions, CBS, AP, NCRRR, no murmurs, flat, NABS, soft, full pulses, Hgt=120mg/dL On second hospital day (5 day of life), IV medications were continued. Oxygen support was continued. th On third hospital day (6 day of life), IVF was continued with SAP. Oxygen support was continued. IVF-TF: D10W 148.6, Na 2cc, K 2cc, Ca 3.4cc; 156cc to run at 6-7 ugtts/min for 24h was given. IV medications were continued. VS were monitored every CR 140 RR 39 T 37.2 hour. HGT was done every 24h. Fair activity, fair cry, soft abdomen, withdraws to pain, Hgt 120mg/dL, tolerates 6cc th On fourth hospital day (7 day of life), OGT feeding at 5ml q3 with SAP was started. Oxygen support was done. IVF: D10W 86.1ml, (3) Na 2cc, (2) K 1.7cc, (200) Ca 3.4cc, (2.5g) AA 70.8cc; 164ml to run at 6-7 ugtts/min was given. IV medications (Ampicillin, Gentamicin, APL, Erythromycin) were continued. Patient was kept thermoregulated. HR 148 RR 40 T 36 Fair activity, tolerates 4On same hospital day, patient was referred to Dr Juico. Ampicillin and Gentamicin were shifted to 5cc, withdraws to pain, (ceftazidime 50mg TIV q8(30mkd), oxacillin 80mg TIV q12 (47mkd) and amikacin 25mg TIV q24 (15mkd). Patient was )apnea, soft abdomen, kept thermoregulated. full pulses, (-) eye d/c On same hospital day, patient was referred to Dr. Cruda. Diagnostics requested were repeat CBC with PC and cranial UTZ. On same hospital day, diagnostics requested were blood typing, PT and PTT. FFP was to be transfused 25ml Hgb 8.2 Hct 0.26 to run for 3 hours properly matched. Patient was for Cranial UTZ tomorrow. Vitamin K 1mg TIM was given Neutrophils 69 immediately. Monocytes 6.3 Lymphocytes 24.7 WBC 8 Platelets 75 th On fifth hospital day (8 day of life), FFP transfusion was deferred. Patient was for FWB transfusion 34cc to run for 3-4 hours properly typed and crossmatched 120cc/kg. Losses were monitored and was replaced with PNSS volume per volume. Watch out for progression of neurologic deficit. Fair activity; fair suck; tolerates 5 ml; (+) apneic episodes, soft fontanel; SCE; (-) retractions; CBS; AP; NRRR; (-) murmurs; flat; NABS; soft; full pulses; HGT: 120 mg/dl th On the 6 hospital day (9 day of life), MF with SAP was continued. O2 support was continued. IV medications were also continued. HGT were monitored once a day. Vital signs were also monitored every hour. CR: 140 RR: 39 T: 37.2 Fair activity/cry/suck Soft abd; withdraws to pain HGT: 120 mg/dl Tolerates 6 cc th th On the 7 hospital day (10 day of life), OGT feeding was started at 5 ml every 3 hours with SAP. O2 support via funnel was continued. Previously ordered medications were also continued. Patient was kept thermoregulated. th th Fair activity; best response: pain/stimuli; soft, nonbulging fontanel th On the same hospital day, patient was referred to the neuro-consultant. Ampicillin and Gentamicin was shifted to Ceftazidime, Oxacillin and Amikacin. Patient was kept thermoregulated. Patient was also for repeat CBC with PC and Cranial UTZ. rd From 8 hospital day to 23 hospital day, patient was maintained on previously ordered medications. On day 9, patient was transfused with FWB. Patient was also for cranial UTZ. CSF analysis and quantitative CRP was done. On day 12, repeat blood CS was done. On day 22, CSF analysis was deferred. On day 23, patient was allowed to go home. Blood CS results showed no growth. Take home medications were as follows: MV + Zn drops and Ferlin drops. Patient is still for EEG on OPD basis scheduled on Friday, August 7, 2009.