OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: FEDERICO, Bb Boy Age/Sex: Newborn/M Address: 2501 Callejo Siete del Pilar st. Sta. Ana, Manila Date Admitted: 8/1/09 Admitting Diagnosis: Meconium Aspiration Pneumonia Residents-in-charge: Drs. Nunez/Salloman/Reyes/Manaligod JIC: Cantos/Castelo/Conde/Diaz/Evangelista Clinical Abstract History of Present Illness: This is a case of a newborn live baby boy born full term to a 19 y/o G3P2 (3-0-1-2), via NSD with Apgar score of 2, 6, 9. Upon delivery, suctioning was done, (+) meconium stains. Patient was intubated but was self-extubated after 15 minutes, hence, admission. Prenatal History: Patient’s mother had no pre-natal check-ups. The mother had CBC, urinalysis and ultrasound with unknown results. It was also mentioned that the mother had fever during her pregnancy. She did not take any multivitamins or ferrous sulfate. She also had UTI and took Amoxicillin that later on resolved. She denies having hypertension, DM, thyroid problems, asthma or history of twinning. Birth History: Born full term to a 19 y/o G3P2 (3-0-1-2), via NSD at OMMC. Obstetrical History: G3P2 (3-0-1-2) Physical examination: General: poor activity, poor cry and poor tone Vital signs: HR: 140’s bpm RR:50 T:37.3 Anthropometrics: BW: 3.15 kg L: 51cm BS: 37-38 weeks AOG AS: 2, 6, 9 HC: 32 cm CC: 34 cm AC: 31cm Skin: pale skin color, poor 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 19 y/o G3P2 (3-0-1-2), via NSD at OMMC Meconium Aspiration Pneumonia Plan: Patient was admitted to Pedia-NICU under the service of Drs Nunez/Salloman/Reyes/Manaligod. Consent for admission was secured and patient was placed on NPO temporarily. O2 support via funnel at 8 lpm. IVF: D10w 189 cc x 24 hours at rate of 7-8 ugtts/min. Diagnostics made were CBC with PC, CXR-AP/L, ABG and Blood CS. Therapeutics prescribed were Ampicillin and Gentamicin. Vital signs were monitored every hour. Watch out for any retractions, cyanosis and alar flaring. Hospital No.: 651641
OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: FEDERICO, Bb Boy Age/Sex: Newborn/M Address: 2501 Callejo Siete del Pilar st. Sta. Ana, Manila Date Admitted: 8/1/09 Admitting Diagnosis: Meconium Aspiration Pneumonia Residents-in-charge: Drs. Nunez/Salloman/Reyes/Manaligod JIC: Cantos/Castelo/Conde/Diaz/Evangelista 24-hour history History of Present Illness: This is a case of a newborn live baby boy born full term to a 19 y/o G3P2 (3-0-1-2), via NSD with Apgar score of 2, 6, 9. Upon delivery, suctioning was done, (+) meconium stains. Patient was intubated but was self-extubated after 15 minutes, hence, admission. Prenatal History: Patient’s mother had no pre-natal check-ups. The mother had CBC, urinalysis and ultrasound with unknown results. It was also mentioned that the mother had fever during her pregnancy. She did not take any multivitamins or ferrous sulfate. She also had UTI and took Amoxicillin that later on resolved. She denies having hypertension, DM, thyroid problems, asthma or history of twinning. Birth History: Born full term to a 19 y/o G3P2 (3-0-1-2), via NSD at OMMC. Obstetrical History: G3P2 (3-0-1-2) Physical examination: General: poor activity, poor cry and poor tone Vital signs: HR: 140’s bpm RR:50 T:37.3 Anthropometrics: BW: 3.15 kg L: 51cm BS: 37-38 weeks AOG AS: 2, 6, 9 HC: 32 cm CC: 34 cm AC: 31cm Skin: pale skin color, poor 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 19 y/o G3P2 (3-0-1-2), via NSD at OMMC Meconium Aspiration Pneumonia Plan: Patient was admitted to Pedia-NICU under the service of Drs Nunez/Salloman/Reyes/Manaligod. Consent for admission was secured and patient was placed on NPO temporarily. O2 support via funnel at 8 lpm. IVF: D10w 189 cc x 24 hours at rate of 7-8 ugtts/min. Diagnostics made were CBC with PC, CXR-AP/L, ABG and Blood CS. Therapeutics prescribed were Ampicillin and Gentamicin. Vital signs were monitored every hour. Watch out for any retractions, cyanosis and alar flaring. COURSE IN THE WARDS: st On the 1 hospital day, patient was maintained on NPO. O2 support was continued via hood at 8 lpm. IVF and IV medications were continued. Patient was kept thermoregulated. Vital signs were monitored every hour. Comfortable; RR: 48’s;
(-) retractions, CBS, (-) abdominal distention, soft CXR AP/L: basal pneumonitis, right
Hospital No.: 651641
OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: FEDERICO, Bb Boy Age/Sex: Newborn/M Address: 2501 Callejo Siete del Pilar st. Sta. Ana, Manila Date Admitted: 8/1/09 Admitting Diagnosis: Meconium Aspiration Pneumonia Residents-in-charge: Drs. Nunez/Salloman/Reyes/Manaligod JIC: Cantos/Castelo/Conde/Diaz/Evangelista Patient Discharge Summary History of Present Illness: This is a case of a newborn live baby boy born full term to a 19 y/o G3P2 (3-0-1-2), via NSD with Apgar score of 2, 6, 9. Upon delivery, suctioning was done, (+) meconium stains. Patient was intubated but was self-extubated after 15 minutes, hence, admission. Prenatal History: Patient’s mother had no pre-natal check-ups. The mother had CBC, urinalysis and ultrasound with unknown results. It was also mentioned that the mother had fever during her pregnancy. She did not take any multivitamins or ferrous sulfate. She also had UTI and took Amoxicillin that later on resolved. She denies having hypertension, DM, thyroid problems, asthma or history of twinning. Birth History: Born full term to a 19 y/o G3P2 (3-0-1-2), via NSD at OMMC. Obstetrical History: G3P2 (3-0-1-2) Physical examination: General: poor activity, poor cry and poor tone Vital signs: HR: 140’s bpm RR:50 T:37.3 Anthropometrics: BW: 3.15 kg L: 51cm BS: 37-38 weeks AOG AS: 2, 6, 9 HC: 32 cm CC: 34 cm AC: 31cm Skin: pale skin color, poor 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 19 y/o G3P2 (3-0-1-2), via NSD at OMMC Meconium Aspiration Pneumonia Plan: Patient was admitted to Pedia-NICU under the service of Drs Nunez/Salloman/Reyes/Manaligod. Consent for admission was secured and patient was placed on NPO temporarily. O2 support via funnel at 8 lpm. IVF: D10w 189 cc x 24 hours at rate of 7-8 ugtts/min. Diagnostics made were CBC with PC, CXR-AP/L, ABG and Blood CS. Therapeutics prescribed were Ampicillin and Gentamicin. Vital signs were monitored every hour. Watch out for any retractions, cyanosis and alar flaring. COURSE IN THE WARDS: st On the 1 hospital day, patient was maintained on NPO. O2 support was continued via hood at 8 lpm. IVF and IV medications were continued. Patient was kept thermoregulated. Vital signs were monitored every hour. Comfortable; RR: 48’s;
(-) retractions, CBS, (-) abdominal distention, soft CXR AP/L: basal pneumonitis, right
Hospital No.: 651641
On the 2 hospital day (D1OL), patient was started on milk feeding at 5 ml every 3 hours. O2 support was discontinued. Previous medications ordered were continued. Patient was kept thermoregulated.
HR: 140; RR: 40; T: 36.5 Comfortable, (-) alar flaring, SCE, CBS, (-) retractions, (-) murmurs, soft abdomen, full pulses Hgb: 19.4 Hct: 56 S: 70.2 M:6 E: 0.5 L: 23.3 Platelet: 291 WBC:22.4
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On the 3 hospital day (D2OL), milk feeding with SAP was continued. IVF was shifted to heplock. Ampicillin and Gentamicin were continued, now on day 2. Patient was placed on phototherapy with precaution. Patient was also kept thermoregulated. Vital signs were monitored every hour. Comfortable; CBS; (+) jaundice; On the same day, IV medications were given through IM. CBC with PC was asked to be repeated (-) abdominal distention; soft; on Day 3 of medications. Tolerates 30 cc On the 4 hospital day (D3OL), milk feeding with SAP was still continued. Ampicillin and Gentamicin was continued, now on Day 3. Phototherapy with precaution was also continued. CBC with PC was repeated. Vital signs were monitored every hour.
Comfortable; CBS; (+) jaundice to legs; (-) abdominal distention; soft; (+) rashes, trunk
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