II History & Physical Assessment

GENERAL DATA:
This is a case of Baby Boy Pilapil 4 days of life, male, Filipino, born on July 19, 2013, in Valenzuela, admitted for the first time at JRRMMC on July 22, 2013.

CHIEF COMPLAINT: jaundice

HISTORY OF THE PRESENT ILLNESS

Patient was born term, 39 weeks AOG by LMP with birth weight of 2.8kg, appropriate for gestation age, Apgar score of 8, 9, to a 25 year old G2P1 (1011) via spontaneous vaginal delivery in a private hospital. Prenatal Check-up was regularly done in the same hospital since 4 months AOG. At 2 months at AOG, mother had fever, and so she sought consult at the same hospital, where CBC and urinalysis were done, and was subsequently diagnosed with UTI. She was prescribed amoxicillin 500mg/tab, 1 tablet TID for 7 days. Fever was resolved and so she did not follow-up. At the 17th hour of life, jaundice of face and trunk was noted, but he still had good suck, good cry. He was consequently admitted. Upon admission, Vitamin K, and Hepa B vaccine, were administered, and new born care and photo therapy exposure were done. Complete blood count revealed leukoctosis (14.7) with predominance of segmenters (0.77, and slightly decreased hematocrit (0.36), blood chemistry revealed increased direct bilirubin (1.6mg/dl), and normal indirect (9.2mg/dl) and total (10.8mg/dl) bilirubin, and blood typing revealed Blood type A. He was given Ampicillin and gentamycin./g(13.2 enta 1 day prior admission, repeat blood chemistry revealed increased total (13.2mg/dl), direct (1.13mg/dl) and indirect (11.9mg/dl) bilirubin. Jaundice was still noted. Few hours prior admission, due to financial constraint, patient was transferred to JRRMMC, hence admission.

PAST MEDICAL HISTORY

( - ) meconium aspiration ( - ) Otitis media (age/duration): ( - )anemia ( - )Parasitic Infection ( - )Amoebiasis Contagious Disease: (age diagnosed) ( - )Measles ( - )Mumps ( - )Chickenpox ( - )History of diarrhea ( - ) Food and Drug Allergy

FAMILY HISTORY: Patient is the 6th child of the family Father: 29 years old, apparently well Mother: 25 years old, apparently well Siblings: none PERSONAL AND SOCIAL HISTORY: Father: high school graduate, security guard Mother: college graduate, housewife Residence and Community: lives in a studio type house that is quiet, well lit but not well ventilated Number of Occupants: 3 occupants Source of Water for Drinking: mineral Garbage Disposal: everyday Prevalent Disease in the Community: none

PRENATAL HISTORY: A. PRENATAL HISTORY Circumstances of Pregnancy: Wanted __+___ Unplanned: __+__ POSTNATAL HISTORY: Prenatal Check-Up: Regular since 4 months AOG in Unusual Signs/Symptoms: none Private hospital Medicines: none Medicines Taken: multivitamins, ferrous sulfate, folic acid Congenital Defect: none Exposure to Radiation/ Teratogen: none

B. FEEDING HISTORY Breastfeeding: since birth up to present Formula Feeding: N/A Vitamins/ Mineral Supplements: none

C. IMMUNIZATION HISTORY ( - )BCG ( - )DPT/OPV ( - )Measles ( + )Hapatitis B -1 dose

( - )HIB ( - )MMR ( - ) Varicella ( - ) Hepatits A

D. GROWTH AND DEVELOPMENT HISTORY N/A Birth 1 year old 1-3 years old Smiled 2months walked alone N/A Held head 3 months Sat briefly N/A Toilet training

Rolled over N/A Stood with support N/A Transferred object 4 N/A Stood alone N/A Walking with support N/A

Behaviour Disturbances

REVIEW OF SYSTEMS ENT: (X) cervicolymphadenopathy, (x) cleft lip/palate CNS: unremarkable CVS: (X) murmur GIT: (X) constipation RESPI: (+) cough (+) fast breathing (+) retractions Endocrine: unremarkable GUT: unremarkable

PHYSICAL EXAMINATION
GENERAL SURVEY: Awake irritable, in respiratory distress Vital Signs: CR-131 bpm RR-61cpm TempTemp:36.5C

Wt. 3.1 kg HEENT: normocephalic, (X)caput, (X)cephalhematoma, pink palpebral conjunctivae, anicteric sclerae Pupillary sizw: 2 mm, (+) reactive to light, (X) nasal discharge, (X) congested nasal turbinates, (+) alar flaring, (X)aural discharges, (X) circomoral cyanosis (X) cervicolymphadenopathy (+) supple neck, (X) Jugular venous distention.

CHEST AND LUNGS:

Symmetrical chest expansion, harsh breath sounds (+) crackles, no wheezes

HEART:
Adynamic precordium, normal rate regular rhythm, no murmur

ABDOMEN:
Slightly globular, no mass, no tenderness, normo active bowel sounds

EXTREMETIES: full equal pulses, (X) deformities, (-) edema (+) pinkish nailbeds SKIN: body pinkish, warm, jaundice up to thigh level, lips are moist (X) pallor, CRT, <2_
seconds, skin turgor: goes back easily (X) cold and clammy

NEUROLOGIC EXAMINATION:
Level of Sensorium: (+) awake (x) stuporous (x) lethargic (x) comatose Cerebellum: Can do finger to nose test_N/A_, Heel to Shin _N/A_ GCS: _15_ (E4V5M6)

Cranial Nerve: CN I: NA CN II: pupillary size: 2-3 m equally reactive to light CN III, IV, VI: (+) intact EOM CN V: (+) corneal reflex CN VII: No facial Asymmetry CN VIII: Reacts to loud sounds CN IX, X: (+) can swallow, (+) gag reflex, (+) uvula at midline CN XI: (+) shoulder shrug MOTOR SENSORY DTR

5/5 5/5

5/5 5/5

100%

100% N/A

N/A N/A

N/A

100% 100%

IMPRESSION: Hyperbilirubinemia secondary to ABO incompatibility T/C early onset sepsis

VII - Recommendation
Parents are taught to evaluate the number of voids and evidence of adequate breastfeeding once the infant is home and is encouraged to bring the new born to the hospital, clinic, or primary care practitioner if there are indications of hyperbilirubenimia. A follow up visit to the health care practitioner within 2 or 3 days after discharge to evaluate feeding and elimination patterns and jaundice is important in the post hospital care of the full-term newborn. Growth and development and the changing needs of infants with hiperbilirubin (such as stimulation, exercise, and social contact) are always the responsibility of the parents to comply with the rules and the description given during hospitalization and follow-up care at home. Factors that should be delivered so that the mother can perform the best action in the treatment of infants with hyperbilirubinemia Encourage the mother revealed / reported when babies have disorders of consciousness such as seizures, anxiety, apathy, appetite decreased breastfeeding. Encourage her to use a pump milk for a few days to maintain smooth milk. Provide an explanation of the photo-therapy procedure, a replacement for the lower levels of bilirubin baby. Advised the mother to consider stopping breastfeeding in preventing an increase in bilirubin. Teach about skin care.