CASE 2

GENERAL DATA:

Patient M.M, 12 days old neonate, female, born September 18, 2021, Filipino, from San Roque II, Lamac,
Consolacion, Cebu was transferred to NICU Central on September 24, 2021 due to her diagnosis of
Respiratory Distress Syndrome.

PMI:

The patient’s mother was a 35 year old G3P3 who according to her had her prenatal checkup done at
their barangay health center four times. The mother maintained iron supplement; no history of illicit
drug use, does not smoke and consume alcohol during her pregnancy. Mother also had a history of
hypertension. The mother is currently with a thyroid problem. The baby was born preterm at 34 weeks
via cesarean delivery, breech presentation at Vicente Sotto Memorial Medical Center. Birth weight of
1555grams, Ballard score of 34 weeks, and Apgar Score of 9,9. There was no meconium staining, no cord
coil, no peripartum bleeding. Mother had preeclampsia during pregnancy.

Newborn screening was done. Vaccinations given were Hepatitis B given after birth and BCG vaccine
given at September 22, 2021. M.M. is fed through expressed breast milk feeding. A live preterm baby
with A/S 9,9, BW 1555g, AGA, LBW, BS 34 weeks, was delivered via cesarean delivery due to breech
presentation.

PHYSICAL EXAM (SEPT. 25, 2021):

Upon PE the patient was asleep, no signs of respiratory distress, no fever. The vital signs are as follows:

TEMP: 36.6

HR: 135 BPM

RR: 45 CPM

O2 SAT: 98% AT 2 LPM VIA NASAL PRONG

SKIN: warm to touch, smooth, no scars, good skin turgor and mobility, has jaundice in both left and right
extremities

HEENT: normocephalic, open fontanels, no caput succedaneum, no cephalhematoma, black hair evenly
distributed, no abnormal eye discharge, eyes opens spontaneously, anicteric sclera, patent ear canals,
no signs of abnormal discharge, no deformities, nasal septum at midline, patent nasal passage, no air
flaring, no cleft lip and palate, no oral thrush, pink oral mucosa and tongue.

CHEST AND LUNGS: Upon inspection there was equal chest expansion, no chest lagging, no retractions.
Upon auscultation vestibular breath sounds was heard all over both lung fields, no crackles, no rhonchi,
no wheezing
CVS: Upon inspection there was adynamic precordium, no lifts, no heaves. Upon palpation and
auscultation there was normal rate and rhythm, distinct heart sounds, no murmurs, no thrills, HR of 135
bpm.

ABDOMEN: soft and globular, no masses, no signs of lesions, umbilical stump was clean and dry, no
erythema, there was slight jaundice

EXTREMITIES: strong and brisk peripheral pulses, CRT <2 secs, no edema, no deformities

GENITALIA: normal female genitalia and no discharge