OUR LADY OF FATIMA UNIVERISTY

COLLEGE OF MEDICINE
DEPARTMENT OF PEDIATRICS
F2F CLERKS

BIRTH HISTORY:

The patient is a live, born, , single, male, delivered via Normal Spontaneous Delivery, APGAR score 5,6,
Birthweight of 2300 grams

NEONATAL HISTORY:

Patient was born to a 35-year-old, Gravida 3 Para 3 (2101) mother of 33 weeks and 1 days age of gestation.
Maternal blood type is A positive. HbsAg screening and VDRL were nonreactive. Mother claims to have
irregular prenatal check up to a private physician and irregular intake of multivitamins. She is non-
hypertensive and non-diabetic, non-asthmatic, no allergies to food or medication. No other history of
trauma, accident or exposure to toxic chemicals or radiation. On her 3rd trimester, she had episodes
malodorous, gray, and thin vaginal discharge she sought consult and was given unrecalled medication.

MATERNAL HISTORY: FIRST TRIMESTER:

The mother experienced the usual signs and symptoms of early pregnancy such as urinary frequency,
breast tenderness, easy fatigability, nausea and vomiting. On the 1st month of missed period (July 2019),
self-pregnancy test was done, which revealed positive result. On the same month, she consulted a private
physician where the following diagnostic tests such as CBC, Hepatitis B antigen screening, VDRL/RPR, and
fasting blood sugar which revealed normal results. Ultrasound done revealed a single, live, intrauterine
pregnancy compatible to 11 weeks 5 days age of gestation by average crown rump length with good
cardiac and somatic activities. She was given multivitamins 1 tablet per day and folic acid 1 tablet once a
day which she took regularly. She denies any history of accidents, trauma, illnesses or exposure to
radiation and toxic chemicals.

SECOND TRIMESTER

Quickening was felt on 5th month of pregnancy (November 2019). She had regular prenatal checkup and
irregular intake of multivitamins, calcium ,folic acid and ferrous sulfate. Complete blood count, urinalysis,
HBsAg, Oral Glucose Tolerance test, fasting blood sugar and urinalysis were all normal. She denies any
history of accidents, trauma, or any exposure to radiation or toxic chemicals.

THIRD TRIMESTER

Subsequent prenatal checkup as well as intake multivitamins, calcium and ferrous Sulfate were regular,
Abdominal ultrasound was done on March 28, 2018 which revealed a single, live, intrauterine pregnancy
with good cardiac and somatic activities, Fetus in cephalic presentation, antero-fundal grade 3 placenta.
Biophysical score was indicative of good fetal well-being. The patient had an episode of fishy odor, gray
and thin vaginal discharge with no associated pruritus, irritation, erythema, and edema were noted. She
sought consult and was given unrecalled medications.
The present condition started one day prior to admission, she experienced intermittent crampy
hypogastric pain, radiating to the lumbosacral area with a pain scale of 3-5/10, no vaginal discharge. No
associated symptoms such as vomiting, loose stools or fever noted. No consult was done.

Few hours prior to consult, there was persistence of the intermittent hypogastric pain now with a pain
scale of 5/10. This prompted consult at our institution hence admission.

General Survey: awake, irritable, with weak cry and reflexes, in cardiorespiratory distress with the
following vital signs: Temp: 37.0 C C HR: 148 bpm RR: 55/ cpm
Birth weight: 2,300 grams Birth length: 45 cm Head circumference: 30cm

PHYSICAL EXAMINATION UPON DELIVERY

HEENT: Open, flat, soft anterior and posterior fontanels, positive ROR, bilateral, pink palpebral
conjunctiva, white sclera, patent ear canals, with nasal flaring and grunting, moist lips and moist buccal
mucosa
CHEST/LUNGS: Symmetrical chest expansion, with subcostal and intercostal retractions, muffled heart
sounds
HEART: Adynamic precordium, tachycardic, regular rhythm, no murmur
ABDOMEN: Slightly globular, soft, no mass, no organomegaly, with bowel sounds, umbilical
cord has 2 arteries and 1 vein
SPINE: small deviation of spinal area at sacral area with tufts of hair with small dimpling
at the junction between the lumbar and sacral junction
GENITALIA: Normal looking male external genitalia, no urine output yet
EXTREMITIES: No gross deformities, full and equal pulses, CRT <2 seconds
SKIN: Cyanotic, prominent visible veins, no active dermatoses
REFLEXES: Positive Babinski, Moro and Rooting Reflexes

IMPRESSION: Live, newborn, Birth weight of 2,300 grams single, male, delivered via Normal Spontaneous
Delivery, APGAR score 5,6, Ballard’s score 38-39 wks AOG, SGA , Spina bifida occulta

Plan of management : Significant finding on history of irregular intake of Folic acid during period of
pregnancy and P.E. finding of small deviation of spinal area at sacral area with tufts of hair with small
dimpling at the junction between the lumbar and sacral junction
Plan of management : Xray of the spine, referral to neurosurgery for assessment
When spina bifida occulta causes no symptoms, it requires no treatment.
It usually is present at the levels of the 5th lumbar and 1st sacral vertebra. Spina bifida occulta in most
cases is asymptomatic, but symptoms among the population may include back pain, enuresis, loss off
bladder or bowel control , motor or sensory dysfunction, leg weakness and posterior disc herniation.
When it causes tethered cord, surgery to release the tether is sometimes recommended. In
general, for any type of tether surgery, the bones of the spinal column are opened from behind to expose
the full extent of the spinal cord tethering.
Symptoms and their severity generally depend on how many vertebrae are left open and how
big the gaps are. Many cases of SBO are very mild. The gaps in the bones are so small that the spinal cord
is still protected and no damage has occurred. About 1 in 1,000 people with SBO will experience
symptoms, however.