neonatal case presentation 2

8/12/2019 Neonatal Case Presentation 2

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Neonatal Case 2 (Jaundice). 2000/2001

Name: Baby of Juliet Carlos.

DOB: 16.12.00.

Birth weight: 2600 g.

Sex: Male.

Reason of admission of mother: Jaundice.

Age: 2 days.

Date of admission: 18.12.00.

Neonatal History:

The baby was re!ter" #$% w&s'. (is weight at birth was 2600 g. (e cried

i""ediately after birth) and was gi*en to the "other. +gar score for the baby was

8 at 1 "inute and , at % "inutes. -o resuscitation was done) and he did not suffer

fro" resiratory distress. The "other blood grou is +) whereas the baby is +.

(e started breast!feeding) and assed his urine and "econiu". (e was gi*en

rohylactic *ita"in /. (e has been *accinated with BC and (eatitis B.

Maternal and Pregnancy History:

Juliet is a $ years old iliino cashier in suer"ar&et. 3he is not related to her

husband. There is no history of chronic illness or allergy) and she is not

co"laining of any health roble". 4n addition) she is not on any "edication.

3he has 2 healthy boy and girl. The boy is fro" re*ious "arriage and he5s now

years old) and his birth weight was 2800g. The %!year!old girl is fro" her currenthusband and her birth weight was about $ /g. #ra*ida $) ara $'. The "other

didn5t ha*e any co"lications during her re*ious regnancies before or after

deli*eries.

a"ily li*es in /uwaitat in a $!bedroo" aart"ent. The husband is a

business"an and he5s non!s"o&er. They ha*e a dog at ho"e.

This regnancy was lanned by the coule. The "other last "enstrual eriod

#M7' was on 8..2000) and 9 was on 1%.1.2001. 3he started antenatal care by

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the end of the 2nd"onth) and no abnor"alities were detected. 3he too& *ita"in

tablets. 3he has gestational diabetes) otherwise no other co"lications e.g. no rash)

no infection) no fe*er) no swelling in ly"h nodes.

'eliery:

3he resented at 16.12.00 with lea&ing a"niotic li;uor since 8:00 .". abor

started at 10 .". #16.12.00'. CT was used for "onitoring. i;uor color was

nor"al. Baby deli*ered at 11:00 .". 16.12.00 by nor"al sontaneous *aginal

deli*ery #-3


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-or"al uil reaction and red refle=.

9yes "o*e in all directions sy""etrically.

9icanthic fold #he5s iliino'. -o widening between the eyes.

Nose: -or"al shae and si>e.

There no obstruction) no discharge) no choanal atresia or stenosis.

There is no flaring of the alae nasi.

-or"al breathing fro" nose.

Mouth and throat:

Mouth si>e is nor"al. There is no "icrosto"ia.

-o cleft lis or alate.

-o high!arched alate.

Tongue: -or"al si>e) no tongue tie) nor"al color and "o*e"ent.

-o natal teeth) gu" and alate are nor"al) no 9stein earls.

Neck:

-o "asses in the nec&. -o redundant s&in #webbing'.

-or"al "o*e"ent in all direction #no torticollis'.

-o tenderness or swelling on the cla*icle.

CV system:

(eart rate is 1$0@"in. Brachial) radial) fe"oral and dorsalis edis ulses are all resent. +ll ulses are

si"ilar on both sides.

-o brachial!fe"oral ulses delay.

+e= beat could be felt roughly in th intercostal sace about 2 c" fro" the

"id!cla*icular line.

An auscaltation) both 31 and 32 heart sounds are resent. 32 sound is slit. -o

"ur"ur.

Chest examination:

-o e=tra niles. -iles are in the thintercostal sace.

-o breast enlarge"ent.

-o intercostal) subcostal) or surasternal retraction.

esiratory rate is % breath@"in.

An auscaltation) e;ual air entry to both lungs) breath sound is broncho*esicular.

-o added sounds.

Abdomen:

"bilical stu" is resent. -o distention or swelling in the abdo"en.

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3leen is alable 2 c" below costal "argin.

i*er is alable 2 c" below costal "argin.

/idneys are not alable.

-o "asses could be felt.

Genitalia:

7enis is nor"al) no hyosadias) eisadias) or other abnor"alities.

rethral oening is at the ti of the glans enis.

Two testes could be felt in the crotu".

-o herniation.

-o hydrocele.

Extremities and back:

+r"s are sy""etrical with nor"al fingers in the hands. -or"al creases in the hands.

Both legs are sy""etrical with nor"al toes.

-o tenderness on the li"bs.

+ll ?oints are "o*ing without restriction.

(is are nor"al #Artolani and Barlow5s tests showed nor"al stable his'.

There is no cur*ature or abnor"al hair tufts on the bac&. -o ilonidal sinus or

sinal defects.

CNS:

-or"al "uscle tone #no hyotonia or hyertonia'.

-or"al eye "o*e"ent.

-or"al sy""etrical facial e=ression.

-o fasciculation in the tongue.

7ri"iti*e refle=es: all are symmetrical.

Moro5s refle= #*e'.

ooting refle= #*e'.

3uc&ing refele= #*e'.

7al"ar gras refle= #*e'.

7lantar gras refle= #*e'.

+sy""etrical tonic refle= #*e'.

7lacing refle= #*e'.

3teing refle= #*e'.

ee tendon refle=es #*e'.

Measurements:

ength D , c". #,0thercentile'.

Eeight D 2600 g. #0

th

ercentile'. (ead circu"ference D $ c". #,0thercentile'.

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Te"erature D $C.

(eart rate D 1$0@"in.

esiratory rate D % breath@"in.

AAE!7:

18.12.00

F 3uc&ing well) and assed urine.

F oo&s well ?aundiced.

F Chest) C


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Chec& seru" bilirubin to"orrow.

20.12.00

F Eeight D 2$% g.

F Jaundiced Total seru" bilirubin D 1$ "g@d.

F Chest) heart) abdo"en-+.F 7lan:

Continue hototheray.

Chec& seru" bilirubin.

21.12.00

F Child is doing well.

F Chest is clear.

F 3eru" bilirubin D 11 "g@d.

F /ee in hototheray and reeat Total bilirubin to"orrow.

22.12.00


F 3eru" bilirubin D ,.% "g@d.

23.12.00


F Chest is clear.

F 3eru" bilirubin D 8 "g@d.

F Can be discharged.

u++ary:7re!ter" #$% wee&s') +roriate for gestational age) ?aundiced "ale infant who

has been treated.

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neonatal case presentation 2

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