Vous êtes sur la page 1sur 4

Raul J. Pales Jr.

3D JC Pediatrics Group 5

I. Information Data

Date and Time gathered: 10/26/2018

Source of history/information: Mother of the patient

%Reliability: 85%

II. General Data:

Patient Y.C., a 9-day-old, male, Filipino, Roman Catholic, from Basak Pardo, Cebu City. Born
on October 17, 2018 in St. Anthony Hospital. Admitted for the first time in Vicente Sotto
Memorial Medical Center last October 20, 2018 at 2 pm.

III. Chief Complaint:

Hypoglycemia with associated bluish discoloration of the lips

IV. History of Present Illness:


3 days prior to admission, the patient, was delivered via vaginal route as 2.5kg preterm
(based on LMP of the mother) by a G1P1001 mother. The mother recalled that she was
poorly lactating after giving birth thus the patient was only able to feed at least 6 times daily
approximately 1-2 minutes.
7 hours prior to admission, upon the evaluation for discharging, the physician noted a bluish
discoloration around the patient’s lips with associated minimal tremors on extremities. The
physician later told them to admit the patient due to low glucose level (glucometer) but due
to lack of hospital beds they were advised to transfer to VSMMC.
V. Review of systems
a. General: No weight gain noted. Active with a loud cry when hungry.
b. Cutaneous: No rashes, reddish pigmentations around the body
c. Cardiovascular: No jaundice on feeding,
d. Respiratory: No difficulty breathing
e. GI: No vomiting, diarrhea, 2-3 times diaper changes per day, yellowish soft stool.
f. GU: Able to urinate
g. Endocrine/Nervous: Sleeping when not feeding, no paralysis, good feeding pattern
h. Musculoskeletal: No swelling and deformities noted.
i. Hematopoietic: No pallor, no bruises noted.
VI. Personal History
a. Gestational History:

The mother is 31 years old, G1P1001, last menstrual period was on February 2,
2018. Her first prenatal checkup was at 4 months and was given vitamins and was
vaccinated with tetanus toxoid. She had her CBC and urinalysis done but did not
have an ultrasound. Last prenatal visit was at 8 months. She denies history of
hypertension, diabetes, and use of any medications.

b. Birth:
Based on the mother LMP (2/2/18) the patient was delivered preterm at 36 weeks
5/7 age of gestation and was attended by a physician. The patient was 2.5 kg at
birth.

c. Neonatal History:

The patient was noted crying upon delivery. No jaundice, hemorrhage, birth
injuries were noted. Properly sucked but minimal milk was produced by the
mother.

d. Feeding history:

Exclusively breastfed. Feeds 8-10/day for 3-5 minutes or until satisfied. No


supplemental formula was given.

VII. Immunization history:

The patient received BCG and HBV at birth

VIII. Family History

Parents are separated which the mother did not elaborate. The mother is 31 years old,
jobless, and receives financial support from the patient’s father and her parents. She denies being
hypertensive, diabetic, and other heredofamilial diseases.

IX. PHYSICAL HISTORY


a. General Survey:

Patient was conscious and displayed a symmetric posture with flexed extremities
with active movements and good muscle tone. No gross congenital abnormities
noted. IV access on dorsum of right hand.

b. Vital Signs:

RR: 53 bpm (abdomen) Temperature: 36.8 C (axillary)

HR: 147 cpm (auscultation)

Weight: 2.5 kg

BP: not assessed

c. Anthropometric measurements

Head Circumference: 32 cm (below 50th percentile or -2 sd z-score)

Length: 50 cm (between 90th and 75th percentile)

Weight: 2.5 kg (below 50th percentile or -2 sd)

Chest Circumference: 30 cm

d. Skin:
Reddish brown, leathery texture and with good turgor. No rashes, edema nor
jaundice noted. Lanugo not seen.

e. HEENT:

Fine black hair evenly distributed throughout the head, symmetric with no
molding noted. Anterior fontanel approx. 2x2 cm, posterior fontanel was barely
palpated, both are not bulging nor sunken. Lids are open and slightly icteric
sclerae. Ears are soft and pliable with some cartilage and instantly recoil. Pinna at
the level of outer canthi of eyes. Nasal septum midline, no alar flaring, no
discharges, no tenderness over paranasal sinuses. Mouth pink, moist gums, intact
soft and hard palate, uvula midline, tongue moves freely, symmetrical with short
frenulum. Neck is short, thick, able to flex and extend but cannot support full
weight of the head, creased with skin folds, trachea midline, and thyroid gland not
palpable, intact clavicle.

f. Chest and lungs

CC: 30 cm. Cylindrical with equal AP: T diameters, symmetrical, abdominal


breather. No intercostal retractions. Areola less than 1 cm.

g. Heart:

No murmurs, PMI at left 4th intercostal space midclavicular line.

h. Abdomen:

No remnants of umbilical cord noted. Globular in shape, and soft on palpation.


Bowel sound hardly appreciated.

i. Genitalia:

Penis is 2 cm uncircumcised, marked phimosis with meatus at center. Descended


testes, down with good rugae.

j. Anus:

Patent, no diaper rash noted.

k. Extremities:

Flexed, full ROM, symmetric, clinched fist, and flat soles with minimal creases. No
extra fingers nor toes, creases only anterior 2/3 on palm and sole. Even gluteal
folds.

l. Trunk and Back

Straight, flexed posture, no gross defect of spine noted. No abnormal


pigmentation, hairy patches.

X. Neurologic System:
a. Neuromuscular Maturity:
Posture: Legs are flexed

Square window: Hands partially flexed to wrist forming 30 degrees angle

Arm recoil: Arms instantly spring back to a flexed position

Popliteal angle: Knees difficult to bend

Scarf signs: Elbows hardly moved across the chest

Heel to ear: Knees difficult to bend

b. Reflexes

Moro Grasp Rooting and Swallowing Tonic neck Babinski


sucking
(+) (+) (+) (+) (+) (+)

XI. Logical Impression

Symptomatic Persistent Infection Neonatal


Transient Hypoglycemia Seizures
Hypoglycemia
Low glucose level (+) (+) (+) (-)
Fever (-) (-) (+) (-)
Tremors (+) jitteriness (+) jitteriness (-) (+) tonic,
clonic

XI. Treatment Plan