OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila
Name: FERRERA, Baby boy Age/Sex: Newborn/M Address: 4026 Ramon-Magsaysay Blvd., Sta Mesa, Manila Date Admitted: 8/8/09 Admitting Diagnosis: Hypoxic Ischemic Encephalopathy Residents-in-charge: Drs. Salloman/Ang/Manaligod JIC: Como Clinical Abstract
Hospital No.: 651873
History of Present Illness: st This is a case of a newborn live baby boy full term to a 35 y/o G4P2 (3-0-0-2), 35-36 weeks AOG via NSD at OMMC. On the 1 hour of life, patient was seen with no activity, no respiration and poor muscle tone. GCS score for the 1, 5, 10 and 15 mins are 1, 3, 4 and 6 respectively. Prenatal History: st Patient’s mother had 7 prenatal check-ups, done at OMMC. The 1 prenatal check-up was at 20 weeks AOG, last check-up was at 30 weeks AOG. She had CBC, blood typing, utrasound and urinalysis with unrecalled results. Mother took multivitamins and ferrous sulfate during her pregnancy. Mother denied any use of illicit drugs, teratogenic substances nor any exposure to radiation during her pregnancy. She also denies st having hypertension, DM, thyroid problems, asthma and history of twinning. However, she claims to have had fever, cough and colds on her 1 month of pregnancy with no intake of any medication. Birth History: Born full term to a 35 y/o G4P2 (3-0-0-2), 35-36 weeks AOG via NSD at OMMC. Obstetrical History: G4P3 (3-0-0-2) G1 FT, NSD, LBG 6 y/o G2 FT, NSD, BG - deceased G3 FT, NSD, LBG 4 y/o G4 present pregnancy Physical examination: General: no activity, no cry and good tone. Patient is in cardio-respiratory distress Vital signs: HR:70 bpm RR:0 T:35.5 Anthropometrics: BW: 3.15 kg L: 51 cm BS: 37-38 weeks AOG AS: 1,3,4,6 HC: 53 cm CC: 35 cm AC:32 cm Skin: bluish in color, 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, no 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 35 y/o old G4P2 (3-0-0-2), 35-36 weeks AOG via NSD at OMMC. Hypoxic Ischemic Encephalopathy
Plan: Patient was admitted at NICU under the services of Drs Nunez/Salloman/Ang/Manaligod. Patient was intubated at ET4 L9. Continuous ambubagging was done at FiO2 100%. OGT was inserted and opened to drain. IVF given was PNSS 30cc IV bolus and D10 water 200cc x 24 hours at 8-9 cc/hour (60 cc/kg). Diagnostics requested were CBC w/ PC, CXR APL, ABGs, blood typing and blood CS. Therapeutics given were Ampicillin 165g/sup every 12 hours (100mkd) and Amikacin 16g/sup every 24 hours (15mkd). Dopamine drip was started. Hgt was monitored every 8 hours while on NPO. The patient will be suctioned as needed. Patient is in close watch.
osis but tachypneic and with minimal retractions. Hgt was 80mg/dl. Patient was slowly shifted from NPO to trial feeding. Oxygen support was maintained. IVF TF was D10 with Na, K and Ca. Medications were continued. She was ordered for blood C/S the next day. She was kept thermoregulated and suctioned for secretions as needed. On second day of life, phototherapy was started. 2cc/MF q3 was started w/ SAP. Oxygen support via funnel at 4-5lpm was given. HGT monitoring was done OD. Blood CS was facilitated. Medications were continued. IVF was continued. On same day, milk feeding was increased by 5cc q3 per cup every third feeding until 30cc q3 is reached. IVF was shifted to heplock once with full feeds. Oxygen support was continued. Blood C/S was facilitated. Patient was for repeat CBC w/ PC. rd On third day of life, 10cc MF/q3 was continued, it may be increased to 5cc q3 per cup every 3 feeding until 30cc/q3 is reached. IVF was shifted to heplock once with full feeds. Phototherapy, medications and IVF were continued. On fourth day of life, patient was placed on BF/MF with SAP. IVF was shifted to heplock. Medications were continued. Blood CS results were followed-up. NB care and cord care were continued. Warm compress alternating with cold compress was applied to affected area. On fifth day of life, patient was placed on MF/BF as tolerated with SAP. IV access was maintained. Medications were continued. Patient was exposed to phototherapy with proper shields. On sixth day of life, patient was placed on MF/BF as tolerated with SAP. IV access was maintained. Medications were continued. Phototherapy was discontinued. Present antibiotics were shifted to ceftazidime 85mg TIV q12(30mkd) and Oxacillin 140mg TIV q12(49mkd). NB care was continued. Patient was transferred to isolation room. On seventh day of life, patient was placed on MF as tolerated with SAP. Medications were continued. On eight day of life, patient was placed on MF as tolerated with SAP. Medications were continued. On ninth day of life, patient was placed on MF as tolerated with SAP. Medications were continued. On tenth day of life, patient was placed on MF as tolerated with SAP. Medications were continued. Bactoban was applied TID on previous IV sites. On eleventh day of life, patient was placed on MF as tolerated with SAP. Medications were continued. On twelfth day of life, patient was placed on MF as tolerated with SAP. Medications were continued. Patient was for repeat CBC with PC. Patient was kept thermoregulated. On thirteenth day of life, patient was placed on MF as tolerated with SAP. Medications were continued. Patient is for possible discharge tomorrow.