Neonate Case Write-Up

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Baby boy A., preterm, 36 weeks by Ballards score was delivered by Ceasarian section at a private hospital to a 32 year old multigravid with Apgar score 8 and 9 at one and five minutes, respectively. Birth weight was 2.3kg. Birth length 45 cm.

Mother, on the 3rd trimester, had urinary tract infection treated with Amoxycillin 500mg/cap, 1 capsule TID for 1 week. Thereafter she was admitted in a private hospital due to preterm labor where tocolysis was done. Two days prior to delivery, the mother had persistent watery vaginal discharge. She was admitted at a private hospital. Pelvic ultrasound done showed Pregnancy uterine 36 weeks.

Upon delivery, the patient had good cry and activity. On physical examination, patient had features compatible with 36 weeks Ballard’s score. CR 150/min RR 40-50/min T 36.5. He had symmetrical chest expansion with good air entry. No rales noted. Abdomen was soft and globular. Liver was palpable 2 cm below right subcostal margin. No cardiac murmur. Peripheral pulses were good. Capillary refill time was 2 seconds. Neurological examination was essentially normal.

The patient was roomed in with the mother after routine newborn care. He was breastfed per demand. At 6 hours of life, he was observed to have tachypnea at 90/minute with episodes of cyanosis, alar flare, and intercostal retractions.

Family lives in a one-storey shanty along the riverbank of Marikina City, sharing the abode with the maternal side (grandparents). Father works in a shoe factory in Marikina City, earning minimum wage. Grandparents foot the house bills (utilities).

Guide Questions:

1. Identify from the story the pertinent historical information that will lead you to a clinical impression and differential diagnoses 2. Interpret the pertinent historical data and craft the history of present illness . 3. Identify the pertinent objective data or physical findings from the case that will confirm and support the clinical history and may lead you to a clinical impression and differential diagnoses. 4. Discuss the stakeholder analysis that may modify (adversely or otherwise) management of this case from the perspective of work-up and principles of intervention.

Family lives in a one-storey shanty along the riverbank of Marikina City, sharing the abode with the maternal side (grandparents). Father works in a shoe factory in Marikina City, earning minimum wage, which is php419. Grandparents foot the house bills (utilities). The financers of the patient are his father and grandparents. The baby is pre-term at 36 weeks, also has low birth weight 2.3kg (normal is 2.53kg for Filipino babies). The baby is currently experiencing respiratory distress, and if there are medicines, procedures that are needed, the family’s patient may not be able to afford it and the patient’s condition may further aggravate. As mentioned, the  patient’s family lives in a shanty which may cause infection to the baby. the doctor should educate the patient’s mother, and family on the patient’s situation for them to have an educated decision, on the different procedures, medicines and simple to help them raise the patient healthy, and free from infections and other diseases.

5. Present a summary of the salient features of the case, both the clinical history and physical attributes 6. State your primary clinical diagnosis or Impression and differential diagnoses, if any, and discuss the rationale for each

PRIMARY CLINICAL IMPRESSION: Neonatal sepsis (i think ha! ill review pa later okay lang? -aaron) Ddx| R/I| R/O| Diagnostics|
Neonatal sepsis
(Early Onset Sepsis)| - risk factors for sepsis include: prematurity, maternal infection with GBS, UTI, prolonged rupture of membranes (>24hours prior to delivery), - male sex (4x more affected than female babies, possibly due to sex-link genetic basis) - low birth weight (2.3kg) along with prematurity are important neonatal predisposing factors to infection - may present with prominent...
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