Download UERM MEMORIAL HOSPITAL Aurora Boulevard, Quezon City

UERM MEMORIAL HOSPITAL
Aurora Boulevard, Quezon City
Department of Pediatrics
DISCHARGE SUMMARY
Name: BARAZON, Baby Boy
Address:
3517 Paraiso st., Sta. Mesa, Manila
Pediatric Consultant:
Dr. Nagtalon
Pediatric Residents:
Dr. May Cero/ Dr. Alexis Milan
Clinical Clerk-in-Charge:
Golpeo, Kirsten C.
Age/Sex: NB/Male
Case No.: 0009909
Date of Birth: 12.20.11
Date Discharged: 12.22.2011.
Admitting Diagnosis: Live full-term male, 40 1/7 weeks AOG by LMP delivered via NSD
to a 35-year old G1P1 (1001); Birth weight: 2900 grams; Birth length: 52cm; APGAR
Score 9 and 9, AGA.
Discharge Diagnosis: Live full-term male, 40 1/7 weeks AOG by LMP delivered via NSD
to a 35-year old G1P1 (1001); Birth weight: 2900 grams; Birth length: 52cm; APGAR
Score 9 and 9, AGA.
IDENTIFYING DATA
The patient is a live full-term male, 40 1/7 weeks AOG by LMP delivered via NSD to a 35-year old G1P1 (1001); Birth weight: 2900
grams; Birth length: 52cm; APGAR Score 9 and 9, AGA.
CHIEF COMPLAINT
For newborn care and management
HISTORY OF PRESENT ILLNESS
Upon birth, the patient was acrocyanotic with spontaneous respiration & movement, vigorous cry, no chest retractions, good air
entry and no cleft lip or palate. There is good cardiac tone, soft abdomen, and umbilical cord with 2 arteries and 1 vein. The
patient was warmed, dried, stimulated and given O2 at 10 lpm via funnel. Suctioning was done orally and nasally to ensure patent
airway. APGAR Score was 9 and 9 during the 1st minute and 5th minute of life. He was wrapped and placed under droplight to aid
in thermoregulation. Temperature was maintained at 36.5-37.5oC. Oxytetracycline 1% ointment was applied to both eyes; vitamin
K 1mg was given IM on the right anterolateral thigh. Cord care was done using povidone iodine and 70% isopropyl alcohol. Patient
was roomed in and vital signs were monitored q15 at the first hour, q30 at the second hour, and q1 thereafter.
MATERNAL HISTORY
Menstrual History
Menarche: 14 years old, regular cycle, 3-4 days duration, 4 pads per day moderately soaked,  dysmenorrhea
Obstetric History
G1P0
G1: Present pregnancy, (+) regular PNCU
Gynecologic History
 Sexual transmitted illness, UTI
Sexual History
Coitarche at 33 years old; 1 sexual partner; (+) post-coital bleeding, dyspareunia
Contraceptive History
None
Past Medical History
(+) Food allergy (chicken, egg and seafood) No known drug allergy.
Family History
(-) Hypertension, diabetes mellitus, asthma, allergies
Social History
Nonsmoker and nonalcoholic drinker
PHYSICAL EXAMINATION UPON ADMISSION
General survey
Acrocyanotic, with spontaneous respiration and vigorous cry
Vital signs
HR: 156 bpm
RR: 43 cpm
T: 36.6 oC
Anthropometrics
BW: 2900 g
BL: 52 cm
HC: 32.5 cm
CC: 31.5 cm
AC: 29 cm
Cephalometry
BP: 9 cm
BT: 7 cm
SOB: 9 cm
OF: 10 cm
Skin
Pink, smooth
HEENT
Head: Open, flat non-bulging anterior and posterior fontanelles, (+) right parietal caput,
 cephalhematoma
Eyes: Anicteric sclerae, pink palpebral conjunctivae,  ROR OU, gross abnormalities
Ears: Well-curved pinna, soft ears but ready recoil, normal set ears, auricular deformities, discharge
Nose: Patent nasal passages, septum midline, gross deformities, alar flaring, discharge
Mouth and Throat: No cleft lip or palate, uvula midline, tongue midline
Chest & Lungs
CVS
Abdomen
Extremities
Genitalia/Anus
Reflexes
No gross deformities, symmetrical chest expansion, no retractions, good air entry, clear breath sounds
Adynamic precordium, good cardiac tone, normal rate, regular rhythm
Slightly globular and soft abdomen, normoactive bowel sounds, umbilical cord with 2 arteries and 1 vein, no
masses palpated
No clavicular fracture, complete fingers and toes, gross deformities, edema, full and equal pulses
Bilaterally descended testis; patent anus
Good suck; Moro, plantar and palmar grasp reflex present
COURSE IN THE WARDS
[12.20.11) The patient was admitted at Nursery for newborn care and management. The patient was delievered via NSD. Patient
had caput succedaneum in the parietal area. She has a birth weight of 2900 grams, birth length of 52cms and APGAR score of 9-9.
The patient has a good cry and good cardiac tone. Bathing was done on the 1st hour of life. Tetracycline ointment and Vitamin K was
given to the patient and patient was rommed in at once.
(12.22.11) The patient remained stable without any complications. The patient has good suck and appetite and bowel movement is
regular. The patient is allowed to go home.
PHYSICAL EXAMINATION UPON DISCHARGE
General survey
No cyanosis, good activity
Vital signs
HR: 140 bpm
RR: 47 cpm
T: 37.0 oC
Weight on
2900 grams.
discharge
Skin
No jaundice. Pink and smooth.
HEENT
Head: Open, flat non-bulging anterior and posterior fontanelles
Eyes: Anicteric sclerae, pink palpebral conjunctivae,  ROR OU, gross abnormalities
Ears: Well-curved pinna, soft ears but ready recoil, normal set ears, auricular deformities, discharge
Nose: Patent nasal passages, septum midline, gross deformities, alar flaring, discharge
Mouth and Throat: No cleft lip or palate, uvula midline, tongue midline
Chest & Lungs
No gross deformities, symmetrical chest expansion, no retractions, good air entry, clear breath sounds
CVS
Adynamic precordium, good cardiac tone, normal rate regular rhythm
Abdomen
Slightly globular and soft abdomen, normoactive bowel sounds, umbilical stump seen, no masses palpated
Extremities
No clavicular fracture, complete fingers and toes, gross deformities, edema, full and equal pulses
Genitalia/Anus
Grossly male genitalia, testes bilaterally descended; patent anus
Reflexes
Good suck; moro, plantar and palmar grasp reflex present.
HOME MEDICATIONS/INSTRUCTIONS
1.
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7.
Daily sunlight exposure for 30 minutes before 8AM.
Daily bath using mild soap and lukewarm water.
Daily cord care using 70% isopropyl alcohol 3 times a day.
Breastfeed every 3 hours or per demand.
Burp every after feeding for at least 30 minutes.
Daily tactile, visual and auditory stimulation.
WATCH OUT FOR:
a. Deepening yellowish discoloration up to palms and soles with persistent yellowish discoloration beyond 2
weeks of life.
b. Decreased sucking reflex/refusal of food.
c. Fast breathing with or without bluish discoloration.
Follow up at Dr. Nagtalon’s office after 1 week.
Dr. Cero/Milan
Residents-in-Charge
Borela/Cu/Losito/Nicu
PGIs-in-Charge
Golpeo, Kirsten C.
Clinical Clerk-in-Charge