TASK

To select one patient of the new born baby with abnomality on the clinical area and to

write the case study.

DEMOGRAPHIC DATA

PATIENT NAME : DOTTO DEUS MATALU

AGE : 4/12 MONTHS

SEX :FEMALE

TRIBE : KURYA

NATIONALITY :TANZANIA

ADDRESS : BUZULUGA

OCCUPATION OF THE MOTHER : ENTERPRENEURSHIP

DATE OF BIRTH 12OCT 22

RELIGION CHRISTIAN

PATIENT FILE NO 45-63-89/22

DATE OF ADMISSION 12OCT 22

NEXT OF KIN DEUS MATALU

WARD NIC UNIT BED NO 5

PHONE NO 0784141087
CHIEF COMPLAIN

The child was admitted in neonatal intensive care unit, with chief complain of

Difficulty in breathing, and brain protrusion

HISTORY OF ILLNESS

The history of illness consist of present illness and past illness

HISTORY OF PRESENT ILLNESS

She complain of anencephaly with brain protrusion.

HISTORY OF PAST ILLNESS

on 12oct 22 at 11:46am the child delivered through caesarean section ,for the indication of one previous
scar.the baby born with apgar score of 6 in 1min,and 7in 5min,rescusitation methods was done through
suctions of secretion and oxygen administration .

FAMILY HISTORY

There is no genetic or hereditary diseases on their families , no infectious diseases or chronic medical
condition .

PAST MEDICAL HISTORY

Before admitted in NIC, the baby was given resuscitation and oxygen therapy in the theatre room.

OBSTETRICAL HISTORY

The child was born with complete 37 weeks of gestation age, born with Apgar score as above, on past
illness, with birth weight of 2.5kg. her mother was gravida 3 para 2, abortion 0, and alive 2, in 2018 she
was delivery a baby boy with birth weight of 2.8 kg via caesarean section due to obstructed labor, on the
table below summarizes her obstetrical history.

n years maturity sex Mode Birth Place EBF puerperiu Alive/dead

o of weight of birth duration m
deliver
y
1 2016 term female SVD 3.0 hosp 1.6years 4weeks Alive

2 2018 term boy C/S 2.8 hosp 2years 3weeks alive

IMMUNIZATION STATUS AND SUPPLEMENT

Non was given.

INNITIAL IMPRESSION
The child was conscious but with anencephaly features.

VITAL SIGNS on 12oct22 ,time 22:12pm

Temp 36,4 C, respiratory rate 43b/min, pulse rate 156b/min, oxygen saturation 95%,

LABORATORY INVESTIGATION

Hb 14.6g/dl, RBG 2.3mmol/dl. On 12oct 22,time 12;38pm

PHYSICAL EXAMINATION

SKIN ASSESSMENT

NO rashes, no yellowish coloration, no hyperpigmentation or hypopigmentation, normal skin color

HEAD

Has normal hair colour, the head is small, with cirmference of 25cm, brain protruded out,

NECK

No any enlargement

CARDIOVASCULAR SYSTEMS

No cardiac enlargement, but her chest is very small with wasted muscles, has good chest movements

ABDOMEN

No abdomen distention, contours are normal ,has normal shape abdomen.

GENITAL URINARY SYSTEM

No ambiguous genitalia, complete genital formation, has passing urine normally.

MUSCULOSKELETAL SYSTEM

No disorder observed

NEUROLOGICAL SYSTEM

The baby responds to stimuli, example for touch and pain

MEDICAL DIAGNOSIS

Anencephaly baby

MANAGEMENTS.