OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: RULIDA, Baby Girl Age/Sex: Newborn/F Address: Blk 22 Lot 19 Baseco, Port Area, Manila Date Admitted: 7/31/09 Admitting Diagnosis: Multiple congenital anomaly t/c Edward’s syndrome Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Cantos/Castelo/Conde/Diaz/Evangelista Hospital No.: 651617
Clinical Abstract History of Present Illness: This is a case of a newborn live baby girl born pre term to a 48 y/o G4P4 (3-1-0-4), 31-32 weeks AOG via LTCS x malpresentation, NRFS at OMMC. Upon delivery, patient showed signs of multiple congenital anomaly t/c Edward’s syndrome, hence admission. Prenatal History: Patient’s mother had a total of 4 prenatal check-up, done at OMMC. The first and last prenatal check-up were not mentioned. The st mother had CBC, UA and UTZ done. Results of the diagnostics were also not mentioned. The patient’s mother had UTI on the 1 trimester of pregnancy and took Amoxicillin for a week. Patient’s mother also took multivitamins and ferrous sulfate. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. Birth History: Born pre term to a 48 y/o G4P4 (3-1-0-4), 31-32 weeks AOG via LTCS x malpresentation, NRFS at OMMC. Obstetrical History: G4P4 (3-0-1-4) Physical examination: General: fair activity, good cry, fair tone Vital signs: HR:120s bpm RR:60 T:37.3 Anthropometrics: BW: 1.2 kg BS: 31-32 weeks AOG AS: 6,8 Skin: good skin turgor, (-) rashes, (-) hematoma, (-) desquamation Head: (+)caput, (-)molding, (-)craniotables, (-) cephalhematoma Face: (+) facies, low set ears ENT: (-) conjunctivitis, (-) discharge, (+) patent nose, (-) cleft lip, (-) cleft palate Chest and Lungs: wide spread nipple, (-) clavicular fracture, (+) NRRR, (-)subcostal retractions, clear breath sounds Abdomen: flat, (-) masses Extremities: overlapping of fingers, Rocher bottom feet, (-)cyanosis, (-)edema, (-)club foot, (+)full and equal pulses Reflexes: (+) moro, (+) sucking. (+) grasping Assessment: Live baby girl born pre term to a 48 y/o G4P4 (3-0-1-4), 31-32 weeks AOG via LTCS x malpresentation, NRFS at OMMC. Multiple congenital anomaly t/c Edward’s syndrome 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. Oxygen support via funnel at 6-8lpm was provided. IVF: D10W 96 ml to run at 4cc/kg. Diagnostics requested were CBC with PC, babygram and chromosomal analysis if feasible. Patient was kept thermoregulated.
OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: RULIDA, Baby Girl Age/Sex: Newborn/F Address: Blk 22 Lot 19 Baseco, Port Area, Manila Date Admitted: 7/31/09 Admitting Diagnosis: Multiple congenital anomaly t/c Edward’s syndrome Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Cantos/Castelo/Conde/Diaz/Evangelista Death Protocol History of Present Illness: This is a case of a newborn live baby girl born pre term to a 48 y/o G4P4 (3-1-0-4), 31-32 weeks AOG via LTCS x malpresentation, NRFS at OMMC. Upon delivery, patient showed signs of multiple congenital anomaly t/c Edward’s syndrome, hence admission. Prenatal History: Patient’s mother had a total of 4 prenatal check-up, done at OMMC. The first and last prenatal check-up were not mentioned. The st mother had CBC, UA and UTZ done. Results of the diagnostics were also not mentioned. The patient’s mother had UTI on the 1 trimester of pregnancy and took Amoxicillin for a week. Patient’s mother also took multivitamins and ferrous sulfate. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. Birth History: Born pre term to a 48 y/o G4P4 (3-1-0-4), 31-32 weeks AOG via LTCS x malpresentation, NRFS at OMMC. Obstetrical History: G4P4 (3-0-1-4) Physical examination: General: fair activity, good cry, fair tone Vital signs: HR:120s bpm RR:60 T:37.3 Anthropometrics: BW: 1.2 kg BS: 31-32 weeks AOG AS: 6,8 Skin: good skin turgor, (-) rashes, (-) hematoma, (-) desquamation Head: (+)caput, (-)molding, (-)craniotables, (-) cephalhematoma Face: (+) facies, low set ears ENT: (-) conjunctivitis, (-) discharge, (+) patent nose, (-) cleft lip, (-) cleft palate Chest and Lungs: wide spread nipple, (-) clavicular fracture, (+) NRRR, (-)subcostal retractions, clear breath sounds Abdomen: flat, (-) masses Extremities: overlapping of fingers, Rocher bottom feet, (-)cyanosis, (-)edema, (-)club foot, (+)full and equal pulses Reflexes: (+) moro, (+) sucking. (+) grasping Assessment: Live baby girl born pre term to a 48 y/o G4P4 (3-0-1-4), 31-32 weeks AOG via LTCS x malpresentation, NRFS at OMMC. Multiple congenital anomaly t/c Edward’s syndrome 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. Oxygen support via funnel at 6-8lpm was provided. IVF: D10W 96 ml to run at 4cc/kg. Diagnostics requested were CBC with PC, babygram and chromosomal analysis if feasible. Patient was kept thermoregulated. Course in the Wards: st On the 1 hospital day, at around 9:45 AM, HR was 0. There was no spontaneous breathing. Pupils were dilated and patient was cyanotic. Patient was later on pronounced dead. Post mortem care was rendered. Final diagnosis: Multiple congenital anomalies; t/c Edward’s syndrome; Prematurity. Hospital No.: 651617