August 6, 2011

Preceptor: Dr. Gandelee Taquiqui

Presented By:

Gilsah Fortuno
Faye Shamaine Dumelod
Sinha Gautam

Informant: Mother (Reliability: 80%)

General Data: E.A. , 9 days old male, Filipino, crusaders divine Church of Christ, born on July 18, 2011
and currently residing at San Pablo Isabela, was admitted for the first time at CVMC on July 23,
2011 1:47PM

Chief Complaint: Jaundice

History Of Present Illness: Patient was born full term to a 29 years old G 1P1(1001) mother thru normal
spontaneous delivery at CVMC last July 18, 2011.
The patient was born with good suck and limited cry with a birth weight of 3515 grams. No birth
complications were noted. After giving birth mother is admitted to the OB ward for recovery,
with the patient roomed in with mother.
On the first 2 days of life patient was apparently well.
On the 3rd day of life patient was noticed by one of the nursing staff to have yellowish
discoloration of the skin on blanching of the sternum, icteric sclera, and yellowish palms and
soles. This prompted attention and baby was brought to NICU for phototherapy. After 2 days of
phototherapy, jaundice persisted; thus prompted subsequent admission to Pedia ward of CVMC
on July 23, 2011, 1:47PM.
No signs of abdominal distention, fever, poor feeding , seizures nor change in level of
consciousness noted. Meconium passed on the first day of life characterized as dark green soft
stool. Blood type of mother is type “O” and pt is type “A”.

Prenatal History:
Mother is a non smoker, non alcoholic drinker. With regular prenatal check up and intake of
multivitamins specifically CalVit and CMax of unrecalled dose, bid starting at 4mos, Ferrous
sulphate of unrecalled dose, OD starting at 7 mos.

At 6wks of pregnancy mother had vaginal spotting which prompted consult to a local
obstetrician. Duvadilan of unrecalled dose and frequency for 2wks, PO was given. No
subsequent bleeding thereafter.
There were no history of falls, exposure to radiation and maternal illness during the course of
pregnancy.

Natal History: Born full term to a 29 years old G 1P1(1001) mother thru normal spontaneous delivery
assisted by MD at CVMC last July 18, 2011. The patient was born with good suck and limited cry
with APGAR score of 8 at 1min. Birth weight is 3515 grams.
Postnatal History: Patient had a limited cry, good suck, not in respiratory distress, APGAR score of 9 at
5minutes. Pt received Crede’s prophylaxis and Vt.K after birth.

Feeding History:Pt. was breastfed on demand immediately after birth until after 2days of life
complementary feeding was given. The pt was given Nan-Pro One with 1:1 dilution. On the 7 th
day of life mother stopped breastfeeding and gave only formula milk.

Past medical history: no previous hospitalization. No established allergies.

Immunization: Received 1doseof BCG, 1 dose of HepB

Family History: Paternal side: (+) DM ;(+) asthma(-) hypertension (-) Hepatitis B (-) bleeding disorders
Maternal side: (-) DM ;(-) asthma(+) hypertension (-) Hepatitis B (-) bleeding
disorders

Review of System:
 Skin: (-) irritations
 CNS: (-) seizure
 Cardiorespiratory System: (-) cough
 GI System: (-) Diarrhea, (-) melena, (-) hematochezia, (-) vomiting,
 GU System: (-) hematuria
 Hematologic System: (-) bleeding tendencies
 Endocrine System: (-) fever, (-) sweats, (-) weight loss

Physical Examination
General survey:
Awake, non-irritable, fairly nourished and not in cardiorespiratory distress. Patient is under
phototherapy.
Vital signs:
 CR: 119 beats per min
 RR: 57 breaths per min
 Temp.: 37.5 ˚C
Anthropometrics:
 Weight: 3.5 kilograms
 Height: 57 cm
 HC: 37 cm
 CC: 35 cm
 AC: 38cm
  Skin: soft , dry, (-) pallor, (-) rashes, (-) bruises, crackling pale areas, rare veins, with areas
the body with lanugo, (+) milia on nose
 HEENT:, Normocephalic, hair equally distributed, soft, flat, open anterior and posterior
fontanels, Icteric sclera,PERRLA, (-) ear discharges, formed and firm ear with instant recoil,
(-) alar flaring, , (-)neck vein engorgement, (-)cervical lymphadenopathy, (-) sore throat,
dry lips, moist oral mucosa
 Chest and Lungs: elliptical thorax, symmetrical on chest expansion, with full areola 5-10mm
bud, no chest mass, (-) chest retractions (-)use of accessory muscles for breathing, clear
breath sounds on both lung fields
 Heart: adynamic precordium, PMI at 4th ICS LMCL, normal rate, regular rhythm, no
murmurs
 Abdomen: globular soft, nontender, with normoactive bowel sounds(18/5min), non-rigid,
liver span at 2-3cm below subcostal margin, spleen not palpable.
 Genitalia: grossly male, urethra located centrally on the glans, brownish scrotum with full
rugae, both testes descended into scrotum
 Extremities: no gross deformities of the vertebra, plantar creases on ant 2/3 of sole, no
clubbing, pinkish nail beds, full and equal pulses, capillary refill time 2 seconds
Neurologic Examination
 MSE: awake
 CN I: not assessed
 CN II: not assessed
 CN III, CN IV, and CN VI: not assessed
 CN V: not assessed
 CN VII: no facial asymmetry
 CN VIII: startled to loud noise
 CN IX, X: not assessed
 CN XI: not assessed
 CNX: not assessed
 Motor: symmetric motor movements, with spontaneous recoil when extended from a
flexed position.
 Sensory: cries to pain
 DTR: not assessed
 Primitive reflex: with presence and symmetry of Babinski, rooting, palmar, moro , plantar,
tonic neck reflexes
 Meningeal signs:
 (-) Kernig’s
 (-) Brudzinski
 (-) Nuchal rigidity

Impression:

Hyperbilirubinemia secondary to ABO incompatibility

Salient points:

Neonate presents with jaundice on the 3 rd day of life with no other untoward signs or
symptoms. Icteric sclerae, skin and palms and soles.