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ADMISSION CONFERENCE

ADMISSION CONFERENCE. Clerk Hannah Lea David December 10, 2010. Baby Boy Jandusay. Date of birth: December 9, 2010 Time of birth: 3:14 am. Maternal History. Born to a 27 y/o G1P0 housewife, married to a 32y/o OFW Regular prenatal check-up since 2 mos. AOG

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ADMISSION CONFERENCE

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  1. ADMISSION CONFERENCE Clerk Hannah Lea David December 10, 2010

  2. Baby Boy Jandusay • Date of birth: December 9, 2010 • Time of birth: 3:14 am

  3. Maternal History • Born to a 27 y/o G1P0 housewife, married to a 32y/o OFW • Regular prenatal check-up since 2 mos. AOG • Holy Clinic Navotas– 2 mos. AOG • Fabella Hospital (3 visits)- 7 mos AOG • USTH- 8 mos AOG • Total of >10 visits • Regular intake of multivitamins and ferrous sulfate • Denies exposure to viral exanthems, radiation • Denies intake of illicit / regulated / prohibited / abortifacient drugs • Non smoker, denies alcohol intake during pregnancy

  4. Maternal History • Labs & Ancillaries: • Hep B screening: HBsAg reactive • RPR: Non reactive • OGCT: normal • CBC, U/A: Normal • Last UTZ done 11/12: Single, live, intrauterine pregnancy about 34 weeks & 4 days, BPS 8/8, EFW 2586+/- 387g

  5. Maternal History • LMP: March 21, 2010, AOG: 37-38weeks • (+) Mixed vaginosis- Metronidazole suppository x 7 days at 8 months AOG • (+) Hepatitis B diagnosed 2003 • No history of hypertension, DM, thyroid disorder, preterm labor

  6. Family History • No hx of hypertension, DM, Cardiovascular diseases, thyroid disorder, PTB, hepatitis

  7. Labor History • 10:30 AM BP 140/100 130/100 • LAT: BFHR 150-160 bpm, good variability, (+) accelerations (-) decelerations • 12 MN- BP 120/80 • BFHR 140-150 bpm Good variability, (+) acceleartions (-) decelerations • thinly stained amniotic fluid • 2:30 AM- BP 120/80 • BFHR 140-150 bpm, good variability with accelerations, no deceleration.

  8. Outcome • Live, term, singleton, male via NSD • BW 2.98 kg, BL 50 cm, HC 32 cm, CC 30.5 AC 27cm • APGAR Score 8, 9 • MT 38-39 weeks AOG • AGA

  9. Physical Examination on Admission • VS: HR 154 bpm, RR 61, T: 36.8oC • BW 2.98 kg, BL 50 cm, HC 32 cm, CC 30.5 cm, AC 27cm • Active, good cry, good muscle tone, acrocyanotic • (+) Mongolian spots • (+) caput succedaneum, (+) molding, no cephalhematoma, patent, flat anterior fontanel • (+) ROR, no eye discharge, no anomalies, normal set ears, no preauricular sinus, patent nares, no cleft lip and cleft palate • Clavicle intact

  10. Physical Examination on Admission • Symmetric chest expansion, no retractions, clear and equal breath sounds • Adynamicprecordium, rhythm regular, S1 and S2 normal, no murmurs • Globular abdomen, umbillicus with 2 arteries and 1 vein, soft, no organomegaly, no masses • Genitalia: bilaterally descended testes, good rugae • Femoral pulses full and equal • (-) Barlow, (-) Ortholani • Spine normal curvature, no sacral dimpling, no tufts of hair • no edema, no cyanosis • (+) moro, grasp, rooting, plantar, sucking, swallowing reflexes

  11. At birth • Patient was dried and stimulated to cry • Cord clamping was done • Skin to skin contact • Latching done • Newborn care: • Erythromycin eye ointment 1cm strip OU • Cord care with 70% ethanol • Vitamin K 1mg/IM • Hepatitis B vaccine, 0.5mL/IM on the anterolateral thigh • Hepatitis B Ig 0.5 mL/IM • Vital Signs monitored

  12. Plans • Bathing at 6th hour of life • Patient roomed in and exclusively breastfed • For hearing screening on the 24th hour of life • For newborn screening beyond 48th hours of life

  13. APGAR Score (at 1 minute) Total = 8

  14. APGAR Score (at 5 minutes) Total = 9

  15. ASSESSMENT Live, term, singleton, male delivered via NSD, bw 2.98 kg, bl 50 cm, HC 32 cm, CC 30.5 cm, AC 27 cm, as 8,9, aga(10th – 90th percentile)

  16. Thank you!

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