SALLES

OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Salles, Baby girl Age/Sex: Newborn/M Address: 3209 Narra St. Obrero Tondo, Manila Date Admitted: 7/17/09 Admitting Diagnosis: Prematurity Sepsis neonatorum Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo Clinical Abstract History of Present Illness: This is a case of a newborn live baby girl born pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC. On st the 1 day of life, patient’s CBC with PC results revealed WBC=18, Neutrophils=33, Lymphocytes=59 hence admission. Prenatal History: Patient’s mother was unable to give information on prenatal check-ups. The mother had CBC (PC=426), no blood typing, had UA (trace albumin, WBC=2), no OCCP, had UTZ (uterine pregnancy, single) and no HBsAg done. The patient’s mother had ACS probably NSTEMI. The mother took multivitamins. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. The mother had hypertension during pregnancy, 1 week prior to consult but no medications were taken. Birth History: Born pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC. Obstetrical History: G2P2 (2-0-0-2) Physical examination: General: good activity, good cry and good tone Vital signs: HR:140sbpm RR:50 T:37.3 Anthropometrics: BW: 1.55kg L: 45cm BS: 39-40 weeks AOG AS: 7,9 HC: 29.5cm CC: 25.5cm AC: 23cm 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 pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC Prematurity Sepsis neonatorum 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 BM/Prenan milf with SAP. IVF: D5IMB 124cc to run at 5ugtts/min for 24h (TFI=80cc/kg). Diagnostics AS= 7,9 BW= 1.55kg requested were CBC with PC, CXR AP/L and blood C/S. Therapeutics were Ampicillin 77mg TIVq12 (100mkd) and BS=34mks Gentamicin 7mg TIV q24 (5mkd). Patient was kept thermoregulated and VS was monitored q1. Hgb=145 Hct=42 Neu=33 Lymp=59 WBC=18 PC=273 Hospital No.: 651241 OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Salles, Baby girl Age/Sex: Newborn/M Address: 3209 Narra St. Obrero Tondo, Manila Date Admitted: 7/17/09 Admitting Diagnosis: Prematurity Sepsis neonatorum Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo 24-Hour History History of Present Illness: This is a case of a newborn live baby girl born pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC. On st the 1 day of life, patient’s CBC with PC results revealed WBC=18, Neutrophils=33, Lymphocytes=59 hence admission. Prenatal History: Patient’s mother was unable to give information on prenatal check-ups. The mother had CBC (PC=426), no blood typing, had UA (trace albumin, WBC=2), no OCCP, had UTZ (uterine pregnancy, single) and no HBsAg done. The patient’s mother had ACS probably NSTEMI. The mother took multivitamins. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. The mother had hypertension during pregnancy, 1 week prior to consult but no medications were taken. Birth History: Born pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC. Obstetrical History: G2P2 (2-0-0-2) Physical examination: General: good activity, good cry and good tone Vital signs: HR:140sbpm RR:50 T:37.3 Anthropometrics: BW: 1.55kg L: 45cm BS: 39-40 weeks AOG AS: 7,9 HC: 29.5cm CC: 25.5cm AC: 23cm 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 pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC Prematurity Sepsis neonatorum 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 BM/Prenan milf with SAP. IVF: D5IMB 124cc to run at 5ugtts/min for 24h (TFI=80cc/kg). Diagnostics AS= 7,9 BW= 1.55kg requested were CBC with PC, CXR AP/L and blood C/S. Therapeutics were Ampicillin 77mg TIVq12 (100mkd) and BS=34mks Gentamicin 7mg TIV q24 (5mkd). Patient was kept thermoregulated and VS was monitored q1. Hgb=145 Hct=42 Neu=33 Lymp=59 WBC=18 PC=273 Course in the wards: st On first hospital day (1 day of life), patient was continued on MF (BF/Prenan) with SAP. IVF was shifted to heplock once 30cc is reached. IV medications were continued. Patient was still for blood C/S and CXR. Patient was for phototherapy with Active, good suck/cry, soft proper eye and genitalia shield. Patient was kept thermoregulated and VS were monitored q1. fontanels, CBS, tolerates 30cc q3, (+) jaundice Hgb=145 Hct=42 Neu=33 Mono=6.8 Eos=6.3 Lymp=59.2 WBC=18 PC=273 Hospital No.: 651241 OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila Name: Salles, Baby girl Age/Sex: Newborn/M Address: 3209 Narra St. Obrero Tondo, Manila Date Admitted: 7/17/09 Admitting Diagnosis: Prematurity Sepsis neonatorum Residents-in-charge: Drs. Juico/Villa/Bonus/Ulob JIC: Carandang/Closa/Co/Cruz/Domingo Patient Discharge Summary History of Present Illness: This is a case of a newborn live baby girl born pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC. On st the 1 day of life, patient’s CBC with PC results revealed WBC=18, Neutrophils=33, Lymphocytes=59 hence admission. Prenatal History: Patient’s mother was unable to give information on prenatal check-ups. The mother had CBC (PC=426), no blood typing, had UA (trace albumin, WBC=2), no OCCP, had UTZ (uterine pregnancy, single) and no HBsAg done. The patient’s mother had ACS probably NSTEMI. The mother took multivitamins. The mother had no history of use of illicit drugs, teratogenic substances and exposure of radiation. The mother had hypertension during pregnancy, 1 week prior to consult but no medications were taken. Birth History: Born pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC. Obstetrical History: G2P2 (2-0-0-2) Physical examination: General: good activity, good cry and good tone Vital signs: HR:140sbpm RR:50 T:37.3 Anthropometrics: BW: 1.55kg L: 45cm BS: 39-40 weeks AOG AS: 7,9 HC: 29.5cm CC: 25.5cm AC: 23cm 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 pre term to a 38 y/o G2P2 (2-0-0-2), 34 weeks AOG via post-mortem LTCS x 1 at OMMC Prematurity Sepsis neonatorum 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 BM/Prenan milf with SAP. IVF: D5IMB 124cc to run at 5ugtts/min for 24h (TFI=80cc/kg). Diagnostics AS= 7,9 BW= 1.55kg requested were CBC with PC, CXR AP/L and blood C/S. Therapeutics were Ampicillin 77mg TIVq12 (100mkd) and BS=34mks Gentamicin 7mg TIV q24 (5mkd). Patient was kept thermoregulated and VS was monitored q1. Hgb=145 Hct=42 Neu=33 Lymp=59 WBC=18 PC=273 Course in the wards: st On first hospital day (1 day of life), patient was continued on MF (BF/Prenan) with SAP. IVF was shifted to heplock once 30cc is reached. IV medications were continued. Patient was still for blood C/S and CXR. Patient was for phototherapy with Active, good suck/cry, soft proper eye and genitalia shield. Patient was kept thermoregulated and VS were monitored q1. fontanels, CBS, tolerates 30cc q3, (+) jaundice Hgb=145 Hct=42 Neu=33 Mono=6.8 Eos=6.3 Lymp=59.2 WBC=18 PC=273 Hospital No.: 651241 day of life), BF/MF as tolerated with SAP was continued. IVF was shifted to heplock. Medications were continued. Patient was still for blood C/S. Phototherapy with proper shields was continued. Patient was kept thermoregulated. HR: 138 RR: 48 T:37.6 Hgt:120mg/dL MF 160ml/day TFI(40cc/kg) 140ml Day 2 of life: Active, good suck/cry, no retractions, CBS, no apnea, tolerates20cc q3, no murmurs, no abdominal distension, full pulses, decreased jaundice On same hospital day, BF/MF as tolerated with SAP was continued. IV access was maintained. Medications were continued. Diagnostics requested were CBC with PC. Phototherapy was discontinued. Patient was HR: 120 RR: 48 T:37.6 Hgt:120mg/dL MF 160ml/day kept thermoregulated. TFI(40cc/kg) 140ml Day 2 of life: Active, good suck/cry, no retractions, CBS, no apnea, tolerates20cc q3, no murmurs, no abdominal distension, full pulses, decreased jaundice day of life), MF/BF as tolerated with SAP (breastmilk/prenan) was continued. IV access was maintained. Medications (Ampicillin D2, Gentamicin D2)were continued. Diagnostic HR: 120 RR: 50s T:37 requested was repeat CBC with PC. Phototherapy was discontinued. Active, good suck, CBS, no retractions, no apnea, no jaundice, (+) skin lesions pustular erythematous maculopapular lesion over the abdomen, CXR results: pnuemonia On fourth hospital day (4 day of life), MF with SAP (BF/prenan only) was continued. IV medications(Ampicillin D2+1, Gentamicin D3) were continued. Diagnostics requested was repeat CBC with PC tomorrow HR: 120 RR: 40 morning. Patient was kept thermoregulated. VS was monitored q1. Active, good suck, CBS, no abdominal distention, soft abdomen, (+) erythematous skin lesion on the trunk area On fifth hospital day (5 day of life), MF with SAP was continued. Heplock was maintained. Medications (Ampicillin D3+1, Gentamicin D4)were continued. Patient was for phototherapy with proper shields. VS was monitored q1. HR: 140 RR: 40 T:37 Active, good suck, CBS, no abdominal distention, (+) jaundice, (+) pustular skin lesions on the abdomen Hgb: 11 Hct: 0.24 Neu: 62.6 Mono: 8.4 Eos: 0.9 Lymp: 26.2 WBC: 9 PC: 181 On sixth hospital day (6 day of life), MF as tolerated with SAP was continued. IV access was continued. Medications(Ampicillin D5, Gentamicin D6) were continued. Blood C/S results were followed-up. HR: 150 RR: 50 T:37.2 Active, good suck, CBS, ↓↓ jaundice, ↓ pustular skin lesions on the abdomen Hgb: 12.1 Hct: 34 Neu: 14.7 Mono: 4.8 Eos: 0.7, 0.9 Lymp: 78.9 WBC: 7.4 PC: 187 day of life), MF/BF with SAP was continued. IV access was maintained. Medications(Ampicillin D6+1, Gentamicin D6) were continued. Blood C/S results were followed-up. HR: 150 RR: 50 T:37.2 Phototherapy with proper shields were continued. Active, good suck, CBS, no retractions, NABS, soft, full and equal pulses, (+) jaundice On eight hospital day (8 day of life), MF with SAP was continued. Medications (Ampicillin D6+1, Gentamicin D3) were continued. Blood C/S results were followed-up. Patient was kept thermoregulated. HR: 150 RR: 50 T:37.2 Active, good suck, CBS, no retraction, soft abdomen, full and equal pulses, th th th th On second hospital day (2 nd On third hospital day (3 rd On seventh hospital day (7 th