ASMPH YL8 CLERKSHIP PROGRAM

OSPITAL NG MAKATI - PEDIATRIC DEPARTMENT

General Data
This is a case of Bb. Girl S., a newborn, female patient who was admitted for the first time in this institution on Au-
gust 20, 2019. The baby’s mother was the informant with strong (95%) reliability.
HPI (Maternal and Birth History)
The patient was born term to a 31 year old G3P2(2002) blood type O+ mother via NSD. The mother noticed amenor-
rhea for 2 months and discovered pregnancy via urine positive pregnancy. She was confirmed to be pregnant at 11 weeks in
Comembo health center via ultrasound, which was also her first check-up. She had another check-up there on her 4th month.
On her 6th month, she started to have monthly regular pre-natal check-ups in Pateros Health Center. She denied any expo-
sure to radiation, viral exanthems, or any teratogenic medications. She had regular intake of folic acid, ferrous sulfate, calcium
lactate, ascorbic acid and multivitamins.
At 20 weeks AOG, she noted quickening. At 25 weeks AOG, she was diagnosed to have UTI and was given Cefalexin
for 7 days. She claimed that she was compliant and became asymptomatic after completion of the medication. Repeat urinaly-
sis revealed resolution of bacteriuria. At 36 weeks AOG, she noted onset of intermittent rotator dizziness lasting for a few
seconds at 4 am, aggravated upon waking up and sudden head movement. She was managed as a case of benign paroxysmal
positional vertigo and was prescribed with Beta-histine 24mg/tab 1 tab BID for 2 weeks. Good fetal movement and no con-
tractions were noted that time.
On the day of delivery, the mother had labor pains prompting consult to Ospital ng Makati ER. Patient is on 41
weeks AOG via LMP and 40 2/7 weeks AOG by UTZ. She was noted to have good fetal movement, no watery or bloody dis-
charge and irregular contractions. On IE, the mother was 7 cm dilated and this prompted her to be admitted in the institu-
tion. At 8 cm cervical dilation, she has regular uterine contraction and was brought up to the delivery room. At 9 cm cervical
dilatation, the membranes spontaneously rupture showing non-foul-smelling whitish amniotic fluid without meconium stain-
ing. After 40 minutes, the patient was delivered via NSD with APGAR score of 9 at 1 minute and 9 at 5 minutes. Essential
intrapartum and newborn care was done. The baby had a good suck and activity. No cyanosis or signs of respiratory distress.
Maternal OB History

Gravida Date of Birth Gender Weight Mode of delivery Complications MD/Midwife Location

G1 11/24/16 Female 3.0 kg NSD - MD Hospital

G2 03/01/17 Female 3.2 kg NSD - MD Hospital

G3 Current pregnancy

Stake Holders Analysis and Family History:

 ASMPH YL8 CLERKSHIP PROGRAM
OSPITAL NG MAKATI - PEDIATRIC DEPARTMENT

Stand/ Intensity Degree of

Stakeholder Stake/ Issue Insight/ Action assumed
Position of Stand Influence

Cannot make own decisions yet and is

Santos BB Girl Patient
entirely dependent on her parents.

She is a housewife and stays at home with

her children. She had irregular prenatal
check-ups which may signify fair health
Mother Primary Ally High High
seeking behavior. Even though the patient
Caregiver
is her 3rd child, she must still be educated
when it comes to taking care of her.

Works in a transportation company and

Breadwinner/
Father Ally High High mainly provides for everyday finances.
Financer
Plans to go abroad to work there.

Will act as secondary caregiver since they

Grandparents Secondary
Ally High Moderate live with the patient. Currently also taking
(Mother side) Caregiver
care of the patient’s other siblings.

Grandmother (Fa- Secondary

Ally Moderate Moderate Act as secondary caregiver and financer.
ther Side) Caregiv-
er/Financer

The mother and father are not married but they are together since 2015. There is a family history of maternal diabe-
tes and paternal hypertension. Currently, their previous house in Comembo is under renovation and they are now living in an
ancestral house together with the patient’s maternal grandparents, two aunts, one cousin, and two siblings. The house has
several floors and rooms are provided for them. Thus, they are not overly crowded. The mother is currently unemployed and
a BS Political Science graduate, while the father is working in a transport company as a driver and sometimes a dispatcher.
They have Meralco as the electricity source, Manila water as the utility water provider and Healthy family as the drinking
water source. Garbage is being collected every other day. They have 3 dogs in the house. There is possible exposure to ciga-
rette smoke from the neighbors. There are no factories nearby. The parents plan to put the baby in a crib next to them in
their bedroom. Presently, their income, together with some help from the grandparents, can support their household expens-
es. However, the father is planning to go abroad to look for a job that can adequately support their growing family.
 ASMPH YL8 CLERKSHIP PROGRAM
OSPITAL NG MAKATI - PEDIATRIC DEPARTMENT
Physical Exam:

General survey: The patient is awake with good activity, good cry and not in respiratory distress

HEAD GROWTH
Temp HR RR Weight Length CHEST ABDOMINAL
CIRCUMFERENCE SCORE

150 49 3000g 49 cm
36.7 C 32cm (p10) 31 cm 28 cm AGA
beats/min breaths/min ( p50) ( p50)

Admission Examination (Description of Findings)

Skin Soft, flat, no rashes, no petechiae, no birthmarks, no bruising, no jaundice, no cyanosis, no salmon
patch

Head and Neck No head molding, no cephalhematoma, no caput succedanum, no bulging and no depression of
fontanels

Eyes No cataract, no scleral hemorrhage, no discharge, intact ROR

Ears, Nose, Throat No cleft lip, no cleft palate, patent nares

Thorax No chest deformities, no retractions, no breast hypertrophy

Lungs Symmetric chest expansion, good air entry, clear breath sounds

Heart Adynamic precordium, normal rhythm, no murmurs, no heaves, no thrills

Pulses Full and equal pulses on all extremities, CRT < 2 sec.

Abdomen 2 umbilical arteries and 1 umbilical vein, soft abdomen, no organomegaly, no masses

Genitalia Grossly female, labia majora is prominent, labia minora is small, no masses, no secretions

Trunk and Spine No tuft of hair, no dimpling, no clavicular fracture

Extremities Symmetric arm and leg flexion, hands are open, no fractures, no dislocations, no clicking sounds
upon eliciting full range of motion, full and equal pulses

Anus Patent anus

Maturity rating with total score of 36 in Neuromuscular (17) and Physical rating (19) corresponds to 38 weeks AOG
by Ballards.
Impression: Term, live birth female delivered via NSD, AS 9,9 AGA
 ASMPH YL8 CLERKSHIP PROGRAM
OSPITAL NG MAKATI - PEDIATRIC DEPARTMENT
Management Plan:
1. Patient education about proper hygiene and proper infant feeding. Emphasize the importance of exclusive breastfeeding.
Teach the mother the proper cord care technique.
2. Review feeding pattern and technique. Continuous monitoring of quality of suck and breast feeding technique observing
adequacy and of position, latch-on, and swallowing. Evaluate the breastfeeding technique of the mother.
3. Assessment of infant’s general health, hydration status, and presence or degree of jaundice. Weigh patient and identify
any new problems and obtain historical evidence of adequate urination and defecation patterns for the infant. Inform re-
garding the expected passing of meconium.
4. Routine newborn care of giving vitamin K, hepa B vaccine, and erythtromycin ophthalmic ointment BCG vaccination,
newborn screening, and other laboratories needed (i.e. serum billirubin, CBC). Since the mother is BT O+, patient’s blood
type should also be checked. Careful review of results of laboratory tests performed before discharge.
5. Encourage compliance to recommended schedule of periodic follow-up and preventive care.
6. Discuss vaccination on follow up but remind the mother now regarding its importance.
7. Discharge patient upon achieving clinical stability and no jaundice, seizures, and other newborn co-morbidities arise. If
the baby is well for 24 hours, the patient may be discharged and asked to follow-up in the Pedia OPD after 24-48 hours.

Course in the wards:

- Upon admission, patient was admitted to OB Ward Room-in (ENC) under the service of Dra. Carnabe/Diez/Nagal.
Patient was kept thermoregulated. Vital signs, and input and output were closely monitored. Patient underwent BCG
vaccination and newborn screening there. Patient was noted to be well.
- On the second hospital day, patient was observed to be well. There are no signs of jaundice, temperature instability,
vomiting, cyanosis, vomiting, seizure, and abdominal distension. The mother was also in good disposition. Laborato-
ry result for patient’s ABO blood typing came revealing blood type O+. Upon observation, patient was assessed to be
well and may go home.