Saint Louis Hospital of the Sacred Heart

Department of Pediatrics

Neonatology Hour

Guests:
Dr. Eleanor Cuarte, FPPN, FPNbM
Dr. Bayani Tecson, MD, FPCS, FPSPS, FPALES

13-day-old preterm
male
History and Physical Exam: Pediatric Clerk Patrick Mariano
Course in the ward: Senior Intern Shaibesh M. Shrestha
Discussion:
Complications of Mechanical Ventilation
Dr Karla Morden- Narito, Resident-in-Charge

When the last breath has taken hold,

only those that remain infinite are memories.
Memories that create ripple through the finite universe.

AskPatrick

GENERAL DATA
BRP, early pre-term
Filipino, Roman Catholic
20 December 2015 at BGHMC
Camp 6, Tuba, Benguet
admitted on 20 December 2015
Aunt and mother: 85%.

HISTORY OF PRESENT ILLNESS

Past Personal History
Maternal History
(-) hypertension, diabetes mellitus, bronchial
asthma, or cancer
(-) surgery
(-) allergies to foods or drugs
(-) medications/ procedures

Past Personal History

Pre-natal History
Mother: 24 years old, G1P0, cognizant at 8 weeks,
(+) home PT
Planned, wanted, without attempts of abortion
1st PNCU: 16 weeks GA- UTZ, UA, Hepa B,
unrecalled test: unremarkable
MV 1 tab OD
subsequent: PNCU: regular, monthly

Past Personal History

Pre-natal History
18 weeks GA: UTZ- single, live intra-uterine male
fetus, breech
EDC: 7 March 2016
20 weeks GA: History of travel: Hong Kong
Isoxuprine 1 tab TID PRN for abdominal cramps
(none taken in)
Self-medicated: conjunctivitis, Tobramycin eye
drops QID (Preg Cat B)

Past Personal History

25-26 weeks GA: dysuria, urgency, hypogastric
pain
Pain: 2/10, pinching, continuous, non-radiating
UA: unremarkable
Reassured, sent home
28-29 weeks GA: sexual contact
(-) pain, vaginal discharge, spotting
Few hours PTA: hypogastric pain
Moderate,
4-5/10, continuous,
radiating
to28-29
backWEEKS
LMP 14 MAY
2015 PMP UNRECALLED,
EDC 7 MARCH
AOG
2015
2016
Persistence consultation

Past Personal History

Natal History
BGHMC via primary LSCS due to premature
labor and breech presentation, 1 nuchal cord
loop
No prior corticosteroid use

Past Personal History

Natal History

1 min
st

CR
60s

Cyanotic

RR 0
No
respon
se

intubated

Limp

pinkish

CR
120s
RR 60s

Past Personal History

5
minute
th

AS 4

Ballards
Score:
29-30 weeks

10
AS 5
minute
th
15
AS 5
minute
th
20
AS 7
minute
th

Past Personal History

NICU

CBCP,
ABO

Umbilical
access

Blood
C&S

D5W
68 ml
x 17H

CXRAPL,
HGT

HGT: 90 mg/dl
(N)
CXR: HMD

4 ml/hr

Ami 19
Pen G 62.5K
(-) Mech
mg IV
IU Q12
vent
q36H
45th minute:
105th:
Ami 23
surfactant,
Pen
mgIV
PPV
63K Q12
q36H

Credes

Vit K

Transf
er

PHYSICAL EXAMINATION
G/S: awake, active motion, good cry, afebrile
VS: CR 150 bpm, RR 58 cpm, T 36.5C
Anthroprometric measurements:
BW:1.25 HC: 26 AC: 22 BL: 35 CC: 22
Skin: warm to touch, no jaundice, no cyanosis
HEENT: (-) caput, AS, lids open, formed and wellcurved pinna, soft but readily recoils, no alar
flaring, no grunting, patent nares, no nasal and
ear discharges, intact ET at level 7, intact OGT,
dry lips, moist oral mucosa, acyanotic, no cleft

PHYSICAL EXAMINATION
Chest: SCWE, subcostal retractions, CBS
Breast: raised areola, 3-4 mm bud, no discharges
Heart: AP, PMI at the 4th ICS, LMCL, NRRR, no
murmurs
Abdomen: flat, non-distended, rare visible veins,
patent umbilical access with no signs of infection,
NABS, tympanitic, soft
Genitalia: grossly male, empty scrotal sac
Anus: patent, no sinus/fistula/bleeding
Extremities: symmetrical, complete set of