Patient R.B.

, 1 day old, Male

CC: Difficulty of breathing

HISTORY:

Baby (NSVD, 36 weeks, non-institutional delivery) was brought to MCS on 5 th hour of life appraised for
intubation and referred to ZCMC. Upon receiving at ER, with noted subcostal retractions, alar flaring,
and grunting, pinkish with spontaneous movement.

Maternal History:

G5P5 (4105)

Noted hypertension during pregnancy (ask highest BP recorded, history of seizures)

Medication history: maintenance medications

Prenatal history: Folic acid intake, number of prenatal visits, TT

Birth history: Year of previous pregnancies, weight of previous babies (LGA – undiagnosed DM),
institutional delivery?

*Premature rupture of membranes

*Who assisted delivery? Equipment used?

*Fever during delivery or labor

*Hx of tobacco/alcohol use

*Maternal nutritional status

*COVID status of mother

General Appearance: no signs of cyanosis, baby is asleep during examination, (status of cry, suck, and
activity)

(Upon admission: pinkish, non-cyanotic, in obvious respiratory distress – alar flaring, grunting,
retractions, poor cry)

Vital signs: HR – 140 bpm, RR – 60, Temp: 37C

(Upon admission: Temp = 35.6C, HR – 140, RR – 70)

Anthropometric measurements: Weight: 2.07kg, Length: 46.3cm,

Head circumference: 30cm, Fontanelles: anterior (2x1cm)

Skin: birthmark at lateral aspect of left thigh, cold extremities

Chest:

Inspection: (+) retractions, (-) alar flaring

Auscultation: clear breath sounds, no heaves and thrills, normal rate and regular rhythm

Quality of pulses: good

Abdomen: No purulence at umbilicus, patent anus

Reflexes: rooting reflex cannot be observed, (+) babinski reflex

Differential Diagnosis

DDX Rule in Rule out

Newborn Respiratory Distress preterm birth, respiratory
Syndrome (RDS) symptoms present immediately
after birth

Meconium Aspiration Syndrome Respiratory distress, DOB, alar Non-meconium stained during
flaring birth

(prolonged labor?, PROM,

meconium stained upon birth?
PE of umbilicus: stained?,
fingernails)
TTN – Transient Tachypnea of DOB Tachypnea persistent after 12-24
the Newborn hours

COVID infection DOB Pending result of swab (mother

and newborn, if mother is (-), NB
swab will not be done)

*vertical transmission
uncommon
Neonatal sepsis DOB, temperature instability

Neonatal pneumonia DOB, retractions, flaring,

RR – 70s
Primary Working Impression:

Live preterm baby boy delivered via NSVD, Ballards Scoring: 36 weeks, BW: 2.07kgs, Small or
Appropriate for Gestational Age?; Neonatal Pneumonia

Management:

 Thermoregulation
 Secure airway: for intubation – refused -> nasal cannula
 Monitor SpO2
 Suction of secretions
 IV line

FLUIDS D10 water if less than 24 hours

After 24 hours: D5IMB depending on glucose
infusion rate (5-8 units per hour)
RESPIRATION O2 nasal cannula
ABG
Chest Xray
INFECTION Ampicillin 100 mkd
Gentamicin

CARDIAC CXR

HEMATOLOGIC CBC
CBG

METABOLIC ABG

OTHERS Thermoregulate
Vaccination: BCG – 0.01ml (ID), Hep B – 0.5ml (IM)
Vit K – 1mg (IM)
Erythromycin
Umbilical Cord Care

NEURO Reflexes
NEPHRO Urine output

DIET Breastfeeding
DERMA
Notes:

*where to palpate in neonates

*RDS: less than 32 weeks

*Criteria for discharge: neonatal pneumonia

LI:

Lester: growth chart

Janna: ballard score

Nas: Neonatal pneumonia – criteria for discharge, pathophysio, pathogens