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Pneumonia

Pneumonia. Magno , Bb. Boy NB/M Born in Cavite On his 9 th hospital day. History of Present Illness. Born pre term to a 24 G1P1 (1001) mother at St. Martin Clinic in Cavite assisted by a hilot via SVD in breech presentation. No noted complications during labor and delivery.

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Pneumonia

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  1. Pneumonia

  2. Magno, Bb. Boy • NB/M • Born in Cavite • On his 9th hospital day

  3. History of Present Illness • Born pre term to a 24 G1P1 (1001) mother at St. Martin Clinic in Cavite assisted by a hilot via SVD in breech presentation. No noted complications during labor and delivery. • The patient was noted to have good activity and good suck • On the 10th hour of life the hilot noted that the patient had poor suck and moderate activity. Upon close PE, they noted that the patient had an imperforate anus.

  4. Patient was immediately brought to the PGH ER. On transit the patient was noted to be in respiratory distress with deep shallow breathing. They also noted circumoral cyanosis hence admission subsequent admission. • Patient was immediately brought to the ER

  5. Birth and Maternal History • Mother is a 24 G1P1 (1001) who had 2 PNCUs at a local health center. There was no note of any infection or illness during the entire course of pregnancy. The patient took multivitamins and Ferrous Sulfate as supplements. • There was no exposure to any teratogen and radioactive substances.

  6. Past Medical History • As above • Family History • (+) hypertension and kidney disease – maternal side • (+) asthma – paternal side • No congenital anomalies/ mental retardation in the family

  7. Personal and Social History • Father is a 24 year old contractual construction worker • Mother is a 24 year old housewife • No one in the family smokes or drinks.

  8. Developmental history: • (+) grasp reflex • (+) sucking reflex • (+)doll’s eye • (+) moro reflex • Immunization History • None given

  9. Nutritional History • The patient was exclusively breastfed

  10. PE at the ER 12th hour of life • Acyanotic, poor activity, poor suck, cold clammy • HR: 120s- 140s RR: 40s GP T: 36.7 – 37.2 • Weight: 1900 g Length: AC: 30cm CC:31cm HC: 32cm • Anictericsclerae, Pink Conjuctivae, Anterior fontanelle open, flat, (+) alar flaring, • (+) intercostal retractions, no crackles no wheezing, Dynamic precordium, no precordial bulging

  11. Dynamic precordium, no precordial bulging, apex beat at the 4th ICS LMCL, no murmurs, no thrills. • Abdomen: soft, non tender, non distended, normoactive bowel sounds, no organomegally • (+) imperforate anus, grossly male genitalia, bilaterally descended testes • CRT 2 secs, FEPP

  12. E/N neurlogic findings • HGT < 40

  13. Course in the ER

  14. Course in the Ward

  15. 1st Hospital Day • A> Preterm32 weeks by PA, SVD in breech presentation, LBB, NID; • HMD vs neonatal pneumonia; • R/O neonatal sepsis; imperforate anus • Management: • IVF: D10 IMB (FM) • Tx: • Ampicillin (200) LD • Amikacin (18) LD • Metronidazole (30) • Blood type: A+ • CBC: Hgb 202, HCt 0.601, pc 149, wbc 12.57, N 0.668, L 0.195 • Na 138, K 5.0, Cl 101, Ca 2.12, Blood GS/CS : no growth • CXR: (+) infiltrates R upper lung field • Referral: PediaSx

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